Complete this form to nominate a provider.

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Your Information
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Your Last Name *
Phone (day)
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Provider Information
Provider's First Name *
Provider's Last Name *
Practice Name *
Street Address
Suite/Apt
City
State
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Phone *
E-mail Address
Comments


Disclosures:
THIS PLAN IS NOT INSURANCE and is not intended to replace health insurance. This plan does not meet the minimum creditable coverage requirements under M.G.L. c.111M and 956 CMR 5.00. This plan is not a Qualified Health Plan under the Affordable Care Act. This is not a Medicare prescription drug plan. The range of discounts will vary depending on the type of provider and service. The plan does not pay providers directly. Plan members must pay for all services but will receive a discount from participating providers. The list of participating providers is on this website. A written list of participating providers is available upon request. You may cancel within the first 30 days after receipt of membership materials and receive a full refund, less a nominal processing fee (nominal fee for MD residents is $5, AR and TN residents will be refunded processing fee). Discount Medical Plan Organization and administrator: Careington International Corporation, 7400 Gaylord Parkway, Frisco, TX 75034; phone 800-441-0380.

This plan is not available in Vermont or Washington.
 

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This is not a health insurance policy.
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