Complete Discount Dental

Check All That Apply

-	Single Group Rate - payroll deducted $9/month
-	Family Group Rate - payroll deducted $12/month
-	Single Discount Dental Program - home billing $108/year
-	Family Discount Dental Program - home billing $144/year
	* no monthly billing available without payroll deduction

* = required field
First Name:	*
Last Name:	*
Address:	*

City	*
State:	*
Province
Zip:
DOB:
SSN:	*
Employer Name	*
Employment Start Date:
Email:
Phone:	*
Fax:
Household Members: (excluding applicant)
Family Member #1:
Family Member #2:
Family Member #3:
Family Member #4:
Family Member #5:
Family Member #6:
Family Member #7:
Family Member #8:
Only complete the section below if your employer does not utilize payroll deduction
Name on credit card:
Credit card type:
Credit card number:
Expiration date:
Benefits include a discount dental and prescription drug program.
This is not insurance.
This program contains a 30 day cancellation policy.
Form #45214-A	Organization New Benefits, Ltd. 14240 Proton Road Dallas, TX 75244

THIS IS NOT INSURANCE.
Payment must be made at the time of service in order to receive a discount.

Disclosures:
This plan is not a health insurance policy.
This plan provides discounts at certain health care providers for medical services.
This plan does not make payments directly to the providers of medical services.
The plan member is obligated to pay for all health care services but will receive a discount from those health care providers who
have contracted with the discount plan organization.
This discount card program contains a 30 day cancellation period.
Member shall receive a full refund of membership fees, excluding registration fee, if membership is cancelled within the first 30 days.
The range of discounts for medical or ancillary services provided under the plan will vary depending on the type of provider and medical or ancillary service received.
Discount Medical Plan Organization New Benefits, Ltd. 14240 Proton Road Dallas, TX 75244