Affordable Health & Benefits
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Discount Plan Application
Primary Cardholder's Personal Information Should Be Listed Directly Below
 

NAME
First 
MI 
Last 
 

ADDRESS
Street 
Apt# 
City  State  Zip# 

PERSONAL INFORMATION
DOB
  Male   Female

CONTACT INFORMATION
Phone 
E-mail Address 

DEPENDENT INFORMATION
Dependents Name (First, M.I., Last)
Date of Birth
Relationship
   
   
   
   
   

COMMENTS
   

HEALTH PLAN OPTION
OPTIMUM HEALTH PLAN:
(Not available in KS, UT, WA, VT)

Includes:
Doctor Visits, Hospital Referral, Teladoc, Doctors Online, Retail Health Clinics, Alternative Medicine, Lab Testing, MRI and CT Scans, Chiropractic, NurseLine(TM), Health Advocacy, Medical Bill Saver™, Pharmacy, Dental, Vision, Global Travel Assistance, Vitamins and Herbal Supplements, Hearing Aids, Diabetic Supplies and Durable Medical Equipment.
$39.95 Monthly
Individual
Family

IH365 PLUS OPTIONS
(must select health plan option to access plus options)
PET CARE PLUS (Includes the following):
Pet Care: Includes savings on Veterinarian Services, pet medications, pet boarding, pet sitting, pet food and more. All household pets are included.
Tax Helpline:  Free Tax Preparation (1040, 1040EZ, 1040A), Year around tax support, discounts on other tax forms, more.
Financial Helpline: Free confidential financial advice and planning by accredited or certified financial counselors

$8.95 Monthly
ROADSIDE ASSISTANCE:
Includes Towing Assistance, Battery Service, Flat Tire Service, Fuel, Oil, Fluid and Water Delivery Service and Lock Out / Lost Keys Services.

$5.00 Monthly
ID SANCTUARY:
Includes Identity Restoration / Alerts, Document Replacement / Recovery, Credit Inquiry Alerts, 1 Bureau Credit Report / Score Monitoring, Bank Account / Credit Card Monitoring, Expense Reimbursement Benefits

$7.95 Individual
$14.95 Family
PERSONAL LEGAL PLAN:
Free Legal Services Include: Attorney Consultations, Attorney Phone Calls on your behalf, Help with Legal Documents, Representation in Small Claims Court, Assistance with Welfare and INS and a Simple and Living Will.
Attorneys only charge $125 an hour or 40% off their hourly rate, whichever is greater. 10% off all contingency-based cases

$4.00 Monthly
SMALL BUSINESS LEGAL PLAN:
Free Legal Services Include: Attorney Consultations, Attorney Phone Calls on your behalf, Attorney Review of Business Documents, Business Letters and Collection Letters Written by an Attorney on your behalf, Registered Agent Services.
Attorneys only charge $125 an hour or 40% off their hourly rate, whichever is greater for additional services.

$7.00 Monthly

Payment Choice   Monthly   Quarterly  

One Time Registration & Processing Fee:
  

                              
$10.00  
Total Amount
$   

SELECT PAYMENT OPTION

  Credit Card Billing:
I hereby authorize Affordable Health & Benefits to charge the above funds to my selected Credit Card. I agree that if any charge is dishonored, whether intentionally or inadvertently, AHB shall be under no liability whatsoever.

  Check here if Name, Address and Contact info are same for Credit Card Billing as AHB Cardholder info (above) and skip to Credit Card Information

NAME
First 
MI 
Last 

ADDRESS
Street 
Apt# 
City 
State 
Zip# 

CONTACT INFORMATION
Day Phone 
E-mail Address 

CREDIT CARD INFORMATION
Exp. mth/yr
Credit Card # no spaces
 

  Automatic Funds Transfer Authorization
I hereby authorize Affordable Health & Benefits to transfer the above funds from my bank account. I agree that if any charge is dishonored, whether intentionally or inadvertently, AHB shall be under no liability whatsoever.
  Bank Name
  
Bank Address
 
  Account Number
  
Routing Number
Check Number

(Place next available check number here, void that check and deduct total program sign up fee from your register)
Representative that sent you to this site
Name: Corporate   ID# 1000

Explanation of Medical Savings & Service Program

I wish to join the AHB health plan. Actual savings will vary depending on the region and the type of specific services provided. AHB savings programs cannot be used in conjunction with any similar style program. All listed or quoted prices or fees are current prices at the date of publication and are subject to change. The AHB program benefits may vary in some areas and the program and providers may be modified at any time.

Effective Date: The first of the month, after the month in which you joined.

Your member instruction guide and cards should be arriving in approximately 7 to 10 business days.

Billing: An automatic draft on the 5th of every month from a checking or credit card of your choice.

Members may cancel their AHB program at any time upon notice via phone, mail, email or fax. Request to cancel must be received 5 business days in advance of the next billing cycle for Member not to be charged for that billing cycle, if the notice of cancellation is not received prior to the billing cycle, then cancellation of payment will occur at the next billing cycle. Cancellations within the 1st 30 days of the program are eligible for a refund of member fees excluding the one-time processing fee. AR and TN residents: A refund of all fees will be issued if membership is cancelled within the first 30 days.

This discount card program is NOT insurance, not intended to replace insurance, and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CRM 5.00. It contains a 30 day cancellation period, provides discounts only at the offices of contracted health care providers, and each member is obligated to pay the discounted medical charges in full at the point of service. For a complete list of disclosures, please click here. Terms and Conditions | Discount Medical Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box 671309, Dallas, TX 75367-1309

Dental Benefit is not available to VT residents. The discount program provides access to the Aetna Dental Access® network. This network is administered by Aetna Life Insurance Company (ALIC). Neither ALIC nor any of its affiliates offers or administers the discount program. Neither ALIC nor any of its affiliates is an affiliate, agent, representative or employee of discount program. Dental providers are independent contractors and not employees or agents of ALIC or its affiliates. ALIC does not provide dental care or treatment and is not responsible for outcomes.

Hospital Discounts NOT available in MD, VT or WV residents.

Global Travel Assistance is not available to NY, FL, OR or WA residents.

Discount Lab Work Benefit is not available to HI, MA, MD, ND, NJ, NY, RI or SD residents.

© 2017 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are registered trademarks of Teladoc, Inc. and may not be used without written permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. Click here to view a Teladoc Access Map.

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ACKNOWLEDGEMENT
  I have read and agree to the above statements.
       Name

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