** We cannot process any form that is altered in any way from the original format below 

Health Benefit Card Plus Enrollment Application
1719 Ashford Hollow, Suite 100, Houston, TX 77077
PH: 281-830-5689 / Fax: 281-493-3367

APPLICANT DATA                                                                                                              Affiliate #_______________________

Applicant Name: _______________________________________________Date of Birth: ____________ Age: _____ Sex: _____

Address: _____________________________________________________ City: _______________ State: _____ Zip: _________

Work Phone:_______________________ Home Phone:__________________________ E-Mail: __________________________

Applicant Signature: _____________________________________________ SSN: __________________ Date: ______________

ELIGIBLE DEPENDENTS/SPOUSE                                                                                                                         (Optional)
NAME                                                                 RELATIONSHIP                       BIRTH DATE                        SOCIAL SECURITY

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________
*Unmarried dependent children ages 19 to 24 must be full time students to be eligible
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MEMBERSHIP PLANS: (Check which Plan you are choosing) - ENROLLMENT FEE:         $20.00 (In addition to first month’s premium)

Premium Health Care Plan:                                         Individual/Family              ___$25.00/month              ___$300.00/yr
Medical Services, Hospitalization, Dental,                         
Vision, Prescription, Chiropractic,                                   Senior                             ___$20.00/month              ___$240.00/yr 
Hearing Care, and 24 Hour Nurse Line,
Rx ADVANTAGE CARD, and DIABETES GOLD
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IF PAYING MONTHLY: ** You Must Enclose a Voided Check for Bank Draft Along With a Check for the Enrollment Fee and the First Month’s Premium.

I authorize Health Benefit Card Plus (HBC Plus) to draft on the authorized checking account on a monthly basis at a rate of  $ _______ per month for the payment of my HBC Plus membership fees.  HBC Plus will continue drafting after my one year contract is complete until I notify them in writing of its cancellation.  I shall notify HBC of any changes in the bank account in order to keep my membership with HBC valid.  HBC administration shall settle any and all disputes regarding bank drafts made by HBC.  Difficulties encountered with drafts may result in a request for annual participation.  Any account unpaid for 30 days is subject to termination.

Signature of Account Holder: ______________________________________ Date: __________________

IF PAYING BY CREDIT CARD:

 

Card Number:

Exp. Date:

Signature of Cardholder: _________________________________________________

Date:

If paying by credit card, HBC Plus will continue drafting on a yearly basis after my one year contract is complete until I notify them in writing of my termination of its policy.

I hereby make application to enroll in HBC Plus Dental HBC Plus Premium Dental or HBC Plus Premium Health Care Plan for a minimum of one year.  I hold HBC Plus blameless for any negligence on the part of the participating provider and agree to discuss all fees with the provider before I receive services.  HBC Plus may terminate this agreement within 30 days without cause by sending a notice of termination and membership cards to the above address.