Discount Medical Plan Application

Membership Benefits Include:

*You will have recurring membership charges billed to your credit card each month.

Registration Summary

  • $3.95 – One Time Setup Fee
  • Recurring Fee (every 1 month)

Today's Total:

(then at first renewal on

Billing Information

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Member Information

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Required *

Not Available to UT, VT, or WA residents.

Your membership is effective upon receipt of membership materials.
This plan is NOT insurance. The plan is not insurance coverage 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 discount card program contains a 30 day cancellation period.

Member shall receive a full refund of membership fees, excluding registration fee, if membership is cancelled within the first 30 days after the effective date. AR and TN residents: A refund of all fees will be issued if membership is cancelled within the first 30 days. Discount Medical Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box 671309, Dallas, TX 75367-1309.

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