Affordable Health & Benefits. Key Silver, Dental and Prescription Discount Health Medical Plans / Join our Key Silver, Dental or Prescription Discount Plan Today. We offer Medical Discount Card Discount Health Cards Discount Health plan includes savings for Physicians Specialists Hospitalization Dentists Prescriptions Chiropractors Alternative Medicine Specialists Eye Exams and more. All pre-existing conditions are accepted. Low cost health insurance alternative Low cost prescriptions low cost eye exams low cost dental affordable health insurance alternative affordable individual health insurance alternative, affordable self employed health insurance alternative low cost health insurance alternative

Affordable Health & Benefits Quality Health Benefits with You in Mind

Discount Medical Plan Application
Primary Cardholder's Personal Information Should Be Listed Directly Below

NAME
First	MI	Last

ADDRESS
Street
Apt#	City	State	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

PLAN OPTIONS

	Key Optimum: (Not available in FL, KS, UT, WA, 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 - ConsultADoctor™! $37.00 a month	Individual Family
	Key Optimum Florida: (Only Available in Florida) 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. $30.00 a month	Individual Family
	Key Dental: (Not available in KS, UT, WA, VT) Includes Dental, Vision, Prescriptions, Vitamins and Herbal Supplements and Diabetic Supplies $21.95 a month	Individual Family
	Key Prescription: (Not available in KS, MS, UT, WA, VT) Includes Prescriptions, Vision, Hearing, Vitamins and Herbal Supplements and Diabetic Supplies $17.95 a month	Individual Family

Payment Choice Monthly Quarterly

One Time Registration & Processing Fee: $30 Processing fee in FL, OH, OR, IL & 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	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 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 written notice is required for cancellation. For a full list of disclosures, click here


	I have read the above statements. Name

OAM001