USA Health Benefits

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Your Information
First Name:
Last Name:
Male:	Female:
Date of Birth:
Email:
Social Security:
Agent:
Address:
Address:
City:
State:
Zip:
Daytime Phone:
Evening Phone:

Dependant Information
Full Name	DOB (MM/DD/YYYY)
Spouse:
Child 1:
Child 2:
Child 3:
List the names and dates of birth of Additional Dependants in the box below. Adding dependants will not change your program price.
Additional Dependants

Select Package Type

Credit Card Information

Card Type:

Full Name:

Card Number:

Expiration Date:

Security Code:
(usually in the back)

Pay by Checking/Savings Account

Bank Name:

Account Type: Checking
Savings

Your Next Check #:
(checking only)

Enter the numbers from the bottom of your check:

Bank Routing Code:
Bank Account Number:

I/We have read, understand and agree to the terms and conditions below.
I/We certify that all the information is true and correct to the best of my/our knowledge

Disclosure

Your signature authorizes US RC GROUP. and/or its assigns to debit your checking/savings account or charge your credit/debit card for the initial payment to start your program. Your initial charge includes your first month's payment plus a non-refundable application fee, and will be processed upon our receipt of this signed form. After your initial payment, your next draft or charge will occur on or after the 1st day of the month following your effective date. For example, if your program's effective date is August 1st; your next draft or charge will be on or after September 1st. If your program's effective date is September 1st, your next draft or charge will be on or after October 1st, and so on. Your signature gives US RC GROUP.. and/or its assigns authority to process your payment each month via an automated debit to your checking or savings account, or charge your credit/debit card, for the exact amount according to the program you selected. If funds in your account are not sufficient to cover the debit,US RC GROUP. assumes NO liability for any non-sufficient or other bank charges that may occur. Further, we reserve the right to attempt to process the payment a 2nd time, on or around the 10th day of the month. Because this is a medical savings program and not a comprehensive health insurance program, there is no waiting period once your program is effective. When used properly with a participating provider, your program entitles you to re-pricing on a wide variety of medical and dental procedures, and discounts on prescription drugs, optical care, chiropractic care, and other services. Savings can vary from provider to provider, and can be substantial. Use of doctor and hospital care may require pre-certification. Refer to your membership materials for specific procedures that must be followed to use your program correctly. Failure to not follow the correct procedures may result in the member not receiving the expected savings. The Accident and Disability policies, if part of your program, are actual insurance policies whereby the policy-holder may be eligible to file a claim for re-imbursement of losses based on events covered in the active policy. USA Health Benefits reserves the right to cancel your program for non-payment with no notice to the member. If you wish to cancel your program, we must receive notice to cancel on or before the 25th of the month, to avoid a charge for the next month. If you cancel after the 25th, your account will be debited for the next month, and your coverage will terminate at the end of that month. To receive a faxed confirmation of your cancellation, fax your request, with a return fax number, to 1-866-313-1194. Program covers only: primary member, spouse, and dependent children under age 19, or under age 25 if full-time student, or if disabled. I certify that the information on this form is correct and I have read and agree to the terms set forth in this document.

Disclosures:
Please note that this is not health insurance and we do not make payments directly to medical service providers. You are obligated to pay for all health care services. You will receive discounts on medical services at certain health care providers who have contracted with the plan. This plan is administered by Discount Medical Plan Organization: United Alliance Corporation. Po Box 1605 La Jolla , CA ,92038 Note to Utah residents: This contract is not protected by the Utah Life and Health Guaranty Association. The program and its administrators have no liability for providing healthcare service or guaranteeing the quality of service rendered. This program is not available in the following states: Nevada, Montana and Vermont.