AmeriPlan® Discount Programs Membership Application
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Member Information
First Name
MI
 Last Name
                                 
 
                                 
Date of Birth of Applicant Male/Female Residence or Work Telephone        Alternate Telephone
   
   
   
 
 
     
     
       
     
     
       
Mailing Address        Apt.#
                                                                 
       
City State Zip
                             
   
           
 
Household Members
First Name Last Name Date of Birth LIST
ADDITIONAL
HOUSEHOLD
MEMBERS ON
REVERSE SIDE
                       
                       
   
 
   
 
   
                       
                       
   
 
   
 
   
                       
                       
   
 
   
 
   
                       
                       
   
 
   
 
   
                       
                       
   
 
   
 
   
E-MAIL-ADDRESS Membership Fees
 
Ameriplan® Corporation
5700 Democracy Drive
Plano, TX 75025
A Discount Medical Plan Organization
AmeriPlan Health® is NOT insurance
I WANT TO PAY MY MONTHLY OR QUARTERLY MEMBERSHIP FEE BY:
 BANK DRAFT:  Please Draft on the
 
3rd or
 
18 of the month.
By Submitting Your enclosed check,you are authorizing the ongoing draft until AmeriPlan® is notified of cancellation in writing.
X
SIGNATURE FOR BANK DRAFT
CREDIT CARD:
    
 Visa
    
 Master Card
    
 Discover
    
 American Express
Card# Expiration Date
                               
   
 
   
   
X
SIGNATURE FOR CREDIT CARD
 
Completed and mail application to:
AmeriPlan, Attn: Application Processing, 5700 Democracy Drive, Plano, Texas 95024
or fax to 469-229-4589
Choice #1 Choice #2
 
Dental Plus
 
Monthly Fee - $19.95
 
Quarterly Fee - $59.85
 
Annual Fee - $239.40
 
Basic Wellness
 
Monthly Fee - $14.95
 
Quarterly Fee - $44.85
 
Annual Fee - $179.40
Choice #3
 
Total Health
 
Monthly Fee - $39.95
 
Quarterly Fee - $119.85
 
Annual Fee - $479.40
 
 
 
 
 First Month Membership Fee
 (Monthly Fee - $14.95/$19.95/$39.95/)
$
 First Quarter Membership Fee
 (Quarterly Fee - $44.05/$59.85/$119.85/)
$
 First Year Membership Fee
 (Annual Fee - $179.40/$239.40/$479.40/)
$
 One-time Registration Fee
         
$

 Dental Plus Registration Fee $20.00
 Basic Wellness Registration Fee $20.00
 Total Health Registration Fee $30.00

NON REFUNDABLE
 TOTAL AMOUNT DUE  
$
Enclose your check for payment and a voided check if paying monthly or quarterly by bank draft -30 day written cancellation notice required.