2 Easy Steps:

1. Enter PCI card holder's Info
2. Enter Payment Info

	Procard Discount Benefits. Dental, Prescription, Vision, Physician & Doctors by phone
Monthly Fee:	49.95/month*

*Please Enter your Team Leader's Access Code:
(If you do not have an access code, please tell us how you found out about us)

*Please Enter PCI card holder's Information:

*First Name:

M.I.:

*Last Name:

*Date of Birth:
MM 01 02 03 04 05 06 07 08 09 10 11 12   DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   YYYY 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2001 2002 2003 2004 2005 2006 2007

*Gender:
Female Male

*Street Address 1:

Street Address 2:

*City:

*State:
AL AK AR AZ CA CO CT D.C. DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MS MO MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA WA WV WI WY

*Zip Code:

*Primary Phone:

Secondary Phone:

*E-mail Address (for confirmation e-mail):

Please Enter Dependent's Information
Your immediate family is included with this plan. Please enter the names of your legal dependents that you would like to have covered below:

Your membership is effective upon receipt of membership materials.

This program is NOT insurance coverage, 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 CMR 5.00. This program contains a 30 day cancellation period. This program provides discounts at certain healthcare providers for medical services. This program does not make payments directly to the providers of medical services. The program member is obligated to pay for all healthcare services but will receive a discount from those healthcare providers who have contracted with the discount plan organization. For a full list of disclosures, click here. Discount Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box 803475, Dallas, TX 75380-3475.

Form # 500-W