How to Enroll
Enrolling is Easy! Just fill out the information on this form, print this form out from your printer, and mail it to the address below with your check for the first month. If you do not have a printer, then send the information below on a piece of paper and state you wish to join.

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    How does Monthly Bank Draft work?
    The HealthPlus Network will automatically withdraw from your checking
    account the monthly amount you choose.

Please fill out and Mail  or call 480-807-4992 to enroll by phone

First Name

Last Name

Address

Apt #

City

State

Zip Code

List Dependents (Family Plan only)

I authorize HealthPlus to draft from my account monthly the amount checked above.
I understand this is a ongoing draft until I notify HealthPlus of cancellation in writing.

X_________________________________________________________________

Signature                                                                                                                           Date

Mail to

When do I receive my ID Card If you enroll by credit card online, you will
Receive your ID Card within 5 days.  If you Choose the Monthly option, you will receive ID cards 5 days from the time we receive your application

Choosing a provider Once you join you will receive a listing of Participating Providers to choose from. We have 100's of providers to choose from. When you visit their office, just show them your ID card for the savings.