MedMore - Affordable Choices in Health Protection

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Application Form/Aplicación
Personal Information (información personal)
First Name (nombre):
Last Name (apellido):	MI (inicial):
Date of Birth (fecha de nacimiento):
Sex (sexo):
Address1:
Address2:
City:
Zip Code:
Country:
State:
Home Phone (tel. casa):
Cell Phone (tel. celular):
E-mail (correo electrónico):

Spouse (esposo/a):
Name (nombre):	DOB (fecha de nacimiento):
Sex: (sexo):	Relationship (relación)

Additional Family Members (familiares adicionales):
Name 1 (nombre):	DOB (fecha de nacimiento):
Sex: (sexo):	Relationship (relación)

Name 2 (nombre):	DOB (fecha de nacimiento):
Sex: (sexo):	Relationship (relación)

Name 3 (nombre):	DOB (fecha de nacimiento):
Sex: (sexo):	Relationship (relación)

Name 4 (nombre):	DOB (fecha de nacimiento):
Sex: (sexo):	Relationship (relación)

Plan Selection (selección de plan):		Cost (costo)
	Basic Plan	$30.00 monthly
	OPTIONAL - Prescription Drug and Vision ValuePaks $0.00 - No Thanks $19.95 - Individual $25.95 - Family of 2 $29.95 - Family of 3 or more	$
	One-time non-refundable application fee that includes shipping	$35.00
	TOTAL	$

Group Plans

If you're a company starting a program or an individual that needs to be added to a company program already in our system please contact Customer Service at 305-662-4081 or by email

Submitting Application/Enviar Aplicación

Click here to submit application for your MedMore Discount Plan Card. I authorize MedMore to charge my account on a montly basis until I cancel the specified service.

Haga un click aqui para enviar la aplicación para su Tarjeta de Plan de Descuento de MedMore. Autorizo a MedMore para cargar mi cuenta todos los meses hasta que cancele este servicio especifico.

Please Note

The MedMore Basic Plan and the Prescription Drug and Vision ValuePaks are not health insurance. MedMore does not make payments directly to the providers of the medical services. These plans provide discounts at certain health care providers and pharmacies for medical services rendered to the MedMore Member(s). After the discounts are deducted, Members are responsible for paying providers and pharmacies directly for their services. Members must make such payments in the manner stipulated by said providers. Such payments are usually required to be paid at the time the health care service is provided to the Member.

SPANISH GOES HERE

I Agree/Estoy de Acuerdo

Assured Options Systems, Inc. d/b/a MedMore
7665 NW 50th Street, Miami, FL 33166
Tel: 305-662-4081 • Fax: 305-662-4077

MM2