Discount Medical Plan Application

Member Information line
Discount Benefits
Dental, Vision, Prescription, Doctors by Phone, Medical Bill Saver, Vitamins, Labs & Imaging, Hearing Aids, Diabetic Supplies

Signup Type
Effective Date
RadDatePicker
Open the calendar popup.
required
Membership Type
required
Date Of Birth
RadDatePicker
Open the calendar popup.
required
First Name
required
Last Name
required
Gender
required
Email
required
Phone
X required
Secondary
X
Address 1
required
Address 2
City
required
State
required
Zip Code
required
Form# 18109-W Required fields are indicated
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Agent Information
rep icon Name Tory Quick
phone icon Primary (920) 354-6306
phone icon Secondary -
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Member Information
Keep your membership profile information up to date to insure usage of your benefits.
Verify Membership
Make sure the chosen membership type is correct, this will affect your benefits and pricing.
Effective Date
The earliest effective date you can choose is tomorrow. Your payment will be drafted on that day of each month.
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rep icon
Contact an Agent
Please contact us for membership registering assistance.
(855) SURE-MED

Not available in KS, UT, FL, VT and WA.

This is not insurance nor is it intended to replace insurance. This discount card program contains a 30 day cancellation period.The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CMR 5.00. This plan provides discounts at certain healthcare providers for medical services. Pharmacy discounts range from 10% to 85% on most medications. This plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all healthcare services but will receive a discount from those healthcare providers who have contracted with the discount plan organization. For a full list of disclosures, please click here. | Terms and Conditions | Discount Medical Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box 671309, Dallas, TX 75367-1309.

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