Membership Enrollment Form

I would like to receive information about other healthcare related offers. I am enrolling in a prescription drug benefit program that will enable me to receive discounts on medications.

Name
Address (Street)
City
State
ZIP
E-mail Address
Home Phone
 
Work Phone
 
Marital Status
  
Section 2: Plan Options
You must select a plan for your application to be processed.
Enter Your ID Number (if you already have an ID Card)
Please do not include the 4-digit prefix (such as "LC02").  If you do not already have a card, please leave this field blank.
  
Enter ONLY the last 6 digits
Code
Please enter the specialized promotion code supplied to you (if applicable).
Section 3: Dependents
Last First MI Relationship Birthday MTH  Birthday DAY  Birthday YR SEX M/F
Member

SELF
Dependent
Dependent
Dependent
Dependent
Section 4: Payment Information
Credit Card Type

Credit Card Number
 
Expiration Date
Please complete the information below ONLY if your billing information is different from the enrollee (shipping) information listed above.
Name as it Appears on Card
Billing Address (Street)
City 
State 
ZIP