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Credit Union, Bank & Association Family Special Rates

Discount Medical Plan Application

Please note indicates a mandatory field

 

YES!  I would like to join Dental Benefits Plus 

Step 1:  Family Membership Plan (includes all financially dependent family members)
Annual Plan     Extra Savings!  Two Months Free!  
Receive 14 months of Dental Benefits Plus and pay for only 12 months.
Only $179.40 ** for your entire family
Monthly Plan  Only $14.95 ** per month for your entire family

** Plus a one-time enrollment fee of $10.00

Step 2:  Credit Union / Bank Membership

 
I am a member of 

Membership at this special rate is subject to verification of membership with the above listed credit union and/or bank.
If your credit union or bank is not listed, please click here to enroll.

Step 3:  Personal Information
Prefix First Name MI Last Name
Address 1 Address 2
City State Zip Phone No.
()-

Social Security #

 Date of Birth  Sex E-mail
-- //  
(Format: JAN/01/1975)

Step 4:  Dependents

Last Name First Name Relationship

Date of Birth (Format: JAN/01//1975)

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//
//
//
//
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Step 5:  Additional Membership Cards
A personalized Dental Benefits Plus card will be issued to the primary member only.  Additional cards may be purchased for the convenience of family members at a cost of $5.00 each (one-time fee).
Yes, I would like additional cards.

Step 6:  Payment Options (select one option below)

OPTION 1:  Pay by Credit Card 
Card Please note, your credit card
Account Number statement will reflect charges from
Expiration Date /   Benefit Services of America.

OPTION 2:  Pay by Automatic Credit Union / Bank Debit (ACH)
Credit Union/Bank
Account Type
Account Number
Routing Number    What is this?

Step 7:  How Did You Hear About Us?
How did you hear about us? 
If you have any comments or additional questions please enter them here.

Step 8:  I Understand This is Not Insurance
Yes, I acknowledge that Dental Benefits Plus is a Discount Dental Plan and is NOT Dental Insurance. Since this is not dental insurance, I will incur out-of-pocket costs which are due to the provider at the time services are rendered.  These out-of-pocket costs are at substantial savings as listed in the fee schedule which I will receive with my enrollment package.
   
 

Step 9:  Read and Acknowledge
By clicking on the "Join Dental Benefits Plus" button below, I hereby authorize payment to Benefit Services of America for my Dental Benefits Plus membership per the payment plan I have selected above, plus a one-time enrollment fee of $10.00.  I understand that I may cancel Dental Benefits Plus within 30 days of my membership effective date and receive a full refund, or I may cancel my membership at any time in the future and incur no additional charges.  If I have selected the annual payment option I understand that the two additional free months received will be placed at the end of the membership term

I further acknowledge that my Dental Benefits Plus membership fees will be automatically deducted and renewed in accordance with the payment plan I have selected.

I understand that I am entitled to the listed special rate because I am a member of a participating credit union or bank.  I also authorize Benefit Services of America to verify my membership with the listed credit union or bank. 


 
 
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DISCLOSURES

THIS PROGRAM IS NOT INSURANCE
This plan provides contracted discounts at certain providers for services and does not make payments to the providers. The plan member is obligated to pay for all services when services are rendered. Not available in all areas. Hospital discounts are not available in Maryland. The range of discounts for medical and ancillary services provided under the plan will
vary depending on the type of provider and medical or ancillary service received.

Discount Medical Plan Organization
Benefit Services of America, Inc., 101 Wymore Road, Suite 300, Altamonte Springs, FL 32714

BSA1042-0908