Membership Agreement Part One

This application, along with Part II in your fulfillment kit, will serve as your membership agreement. Please keep the bottom half for your records. Fax applications to (866) 271-5344, or mail to Ehealthdiscountplan.com, P.O. Box 102, Narberth PA 19072.

STEP ONE: CONTACT INFORMATION

LAST NAME FIRST NAME INITIAL
ADDRESS CITY, STATE, ZIP HOME PHONE
WORK PHONE EMAIL ADDRESS DATE OF BIRTH
SPOUSE’S NAME (IF INCLUDED) DATE OF BIRTH
CHILDREN’S NAMES (IF INCLUDED) 1. 2. 3. 4. DATE OF BIRTH

STEP TWO: CIRCLE BILLING CYCLE AND FEES. A ONE-TIME, NON-REFUNDABLE $20.00 PROCESSING FEE IS REQUIRED

STEP THREE: BILLING INFORMATION—Processing will be delayed on applications received without a form of payment. I will pay by:

Credit card—Mark one:

Visa

Mastercard

American Express

Discover
Account #_____________________________________________________ Expiration Date _________________

  1. Automatic bank draft—please include a voided check with application.
    Bank/Institution Name ______________________________________________________________________
    Name of account holder _________________________________________________________________________
    Routing #_______________________________ Account #_____________________________________________

  2. Use enclosed check (not available for monthly options)

FORM CICAPP ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
MEMBERSHIP AGREEMENT PART ONE--Tear this off and keep for your records.
BILLING CYCLE AND FEES. A ONE-TIME, NON-REFUNDABLE $20.00 PROCESSING FEE IS REQUIRED WITH EACH
APPLICATION.

Renewal Conditions: By joining a plan, you are authorizing CAREINGTON to bill your credit card or checking account for the plan you have selected. This charge shall remain in force until you notify CAREINGTON International Corporation in writing of its cancellation. By joining, you are agreeing to the terms and conditions of the plan and adopting it for a minimum of one year. This plan will automatically renew at the end of your membership term on an annual basis, and your credit card or bank account will be automatically charged or drafted for the appropriate amount. Termination Conditions: CAREINGTON International reserves the right to terminate plan members from its plan for any reason, including nonpayment. Cancellation Conditions: You have 45 days from the date you join to use the plan risk-free. If for some reason within 45 days you are dissatisfied with the plan and wish to cancel and obtain a refund of any membership fees paid, please send a cancellation letter and a request for refund with your name and member number to Member Services, CAREINGTON International at 7400 Gaylord Parkway, Frisco, Texas 75034. If CAREINGTON International is billing you quarterly, semi-annually or annually, CAREINGTON International will, in the event of cancellation of the membership by either party, make a pro-rata reimbursement of the periodic charges to the member. Limitations, Exclusions & Exceptions: This program is a discount membership program offered by CAREINGTON International Corporation. CAREINGTON is not a licensed insurer, health maintenance organization, or other underwriter of health care services. No portion of any provider's fees will be reimbursed or otherwise paid by CAREINGTON. CAREINGTON is not licensed to provide and does not provide medical services or items to individuals. You will receive discounts for medical services at certain health care providers who have contracted with the plan. You are obligated to pay for all health care services at the time of your appointment. Savings are based upon the provider's usual and customary fees. Actual savings will vary depending upon location and specific services or products purchased. Please verify such services with each FORM CODE CICAPP