Complete this form to nominate a provider.

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


Disclosures:
THIS PLAN IS NOT INSURANCE. THIS IS NOT A MEDICARE PRESCRIPTION DRUG PLAN.*
This plan does not meet the minimum creditable coverage requirements under M.G.L. c. 111M and 956 CMR 5.00. The plan provides discounts at certain health care providers for medical services. The range of discounts will vary depending on the type of provider and service. The plan does not make payments directly to the providers of medical services. Plan members are obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount medical plan organization. You may access a list of participating health care providers at this website. Upon request the plan will make available a written list of participating health care providers. You have the right to 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). Discount Medical Plan Organization and administrator: Careington International Corporation, 7400 Gaylord Parkway, Frisco, TX 75034; phone 800-441-0380.

The program and its administrators have no liability for providing or guaranteeing service by providers or the quality of service rendered by providers. This program is not available in Montana and Vermont. This plan is not currently available in Washington. *Medicare statement applies to MD residents when pharmacy discounts are part of program.
 

All contents Copyright Careington International Corporation
This is not a health insurance policy.
Terms and Conditions