No JavaScript detected. Turn it on, or upgrade to Communicator."

Member Application Primary Cardholder's Personal Information Should Be Listed Directly Below Name First  MI  Last  Address Street  Apt#  City  State  Click to Select Not Applicable Air Atlantic Air Europe Air Pacific Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Marianas Islands Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska New Brunswick Newfoundland Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Nova Scotia Northwest Territory Ohio Oklahoma Ontario Oregon Pennsylvania Palau Puerto Rico Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia U.S. Virgin Islands Washington West Virginia Wisconsin Wyoming Yukon Zip#  Personal Information DOB  Male  Female Contact Information e-mail Address  Day Phone  Evening Phone  Fax Phone  Dependents Name (First, M.I., Last) Date of Birth Relationship                     Notes Section     Choose Your Plan Key Gold: (Not Available in CT, MD, NJ, NY, UT, WA) Includes: $500 Daily Hospital Indemnity Benefit, $1,000 Intensive Care Indemnity Benefit $50 Doctor Office Visits, $500 Inpatient Surgery Benefit, $300 Outpatient Surgery Benefit, $25,000 Accident Medical & Accident Dental Benefit with an additional $150 Daily Hospital Indemnity Benefit, $50,000 AD&D, Travel Services and Value Added Consumer Benefits. $157.00/month for Individual $229.00/month for Member & Spouse $279.00/month for Family Individual Member & Spouse Family Key Silver: (Not available in CT, KS, MD, NH, UT, VT) Includes: Hospitalization and Facilities with Medical Health Assistance, Physicians and Specialists, Doctors Online, Dental, Prescriptions, Vision, Chiropractic, Alternative Medicine Specialists, Diabetic Supplies, 24-Hour Nurse Assistance Hotline, Hearing, Medical Travel Assist, Vitamin & Herbal Supplements and Travel Services. Bonus - ConsultADoc! $37.00 a month Individual Family Key Dental: (Not available in CT, KS, NH, UT, VT) Includes Dental, Vision, Prescriptions, Vitamins and Herbal Supplements and Diabetic Supplies $21.95 a month Individual Family Key Prescription: (Not available in CT, KS, MS, NH, UT) Includes Prescriptions, Vision, Hearing, Vitamins and Herbal Supplements and Diabetic Supplies $17.95 a month Individual Family $25,000 Accident Medical & Accident Dental: (Not available in NJ) Includes $25,000 Accident Medical, $150 Daily Hospital Confinement Benefit, $50,000 Accidental Death and Dismemberment and Consumer Benefits Individual or Family: $59.00 Individual Family 4 Tier Prescription Card: Includes Prescription Card and Consumer Benefits $29.95 a month for Individual or Family Individual Family Insured Dental and Vision Plan: (Not available in NY or OR) Includes Insured Dental and Vision benefit and Consumer Benefits Individual: $37.00 a month Family: $49.00 a month Individual Family $5,000 Critical Illness: (Available in All States) Includes $5,000 Critical Illness and Consumer Benefits Individual: $35.00 a month Individual Only Long Term Accident Disability Income Plan: (Available in All States) Includes Long Term Accident Disability Income, Value Added Consumer Benefits and Diabetic & Ostomy Supplies and a $1,000 Accidental Death Benefit Individual: $29.00 a month Family: $37.00 a month Individual Family Payment Choice   Monthly   Quarterly   One Time Registration & Processing Fee:    $30 Processing fee in OH and SC and a $25 Processing Fee in SD    $45.00   Total Amount   $   Please select a Payment Option and fill in all Corresponding Fields   Credit Card Billing I hereby authorize Affordable Health & Benefits to charge the above funds to my selected Credit Card. I agree that if any charge is dishonored, whether intentionally or inadvertently, AHB shall be under no liability whatsoever.   Check here if Name, Address and Contact info are same for Credit Card Billing as AHB Cardholder info (above) and skip to Credit Card Information Name First  MI  Last  Address Street  Apt#  City  State  Click to Select Not Applicable Air Atlantic Air Europe Air Pacific Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Marianas Islands Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska New Brunswick Newfoundland Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Nova Scotia Northwest Territory Ohio Oklahoma Ontario Oregon Pennsylvania Palau Puerto Rico Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia U.S. Virgin Islands Washington West Virginia Wisconsin Wyoming Yukon Zip#  Contact Information e-mail Address  Day Phone  Evening Phone  Fax Phone  Credit Card Information Exp. mth/yr Credit Card # no spaces   Automatic Funds Transfer Authorization I hereby authorize Affordable Health & Benefits to transfer the above funds from my bank account. I agree that if any charge is dishonored, whether intentionally or inadvertently, AHB shall be under no liability whatsoever.   Bank Name    Bank Address     Account Number    Routing Number Check Number (Place next available check number here, void that check and deduct total program sign up fee from your register) Annual Payment by Check or Money Order Option: To join using check or money order, mail completed form and annual payment to: Affordable Health & Benefits, LLC. 1383 Clear Creek Drive Lewisville, TX 75067 Representative that sent you to this site Name: Corporate Office   ID# 1000 Explanation of Medical Savings & Service Program I wish to join the AHB membership plan. This plan is not insurance. Members are responsible for paying the providers promptly for all services received when accessing AHB’s networks. Actual savings will vary depending on the region and the type of specific services provided. AHB savings programs cannot be used in conjunction with any similar style program. All listed or quoted prices or fees are current prices at the date of publication and are subject to change. The AHB program benefits may vary in some areas and the program and providers may be modified at any time. Your new instruction kit and cards should be arriving in approximately 2 weeks. This discount card program contains a 30-day cancellation period. A refund of all fees will be issued if membership is cancelled within the first 30 days after receipt of membership materials. A written notice is required for cancellation. Membership Rates Are Guaranteed for 1 year upon execution of this application. Proxy notice for application in Key Gold, Accident Medical and Long Term Accident Disability I hereby designate and appoint the Secretary of NAIB in office at any particular time, and from time to time as my proxy to receive all notices of meetings of the members, to attend and vote on my behalf at any and all meetings of the members, to execute consents and to otherwise act for me in the same manner and with the same effect as if I were personally present. I authorize my proxy to substitute any other person to act under this proxy, to revoke any substitution, and to file this proxy and my substitution or revocation with NAIB. This proxy shall remain valid until revoked at any time prior to voting at any meeting by executing and delivering a written notice of revocation, or a subsequently dated proxy, to the Secretary of the Association, or by voting in person.    I have read the above statements. Name OAM001 Home| About| Faqs| SignUp| Providers| Team| Network| Contact ©Copyright 2000 Affordable Health & Benefits All Rights Reserved Site Design and Development by DreamTime.net Inc.