DISCLOSURES TO CONSUMERS: AmeriPlan ® Discount Medical Plan Membership Application

AmeriPlan® Corporation 5700 Democracy Drive Plano, TX 75024

These discount medical plans are NOT A Discount Medical Plan Organization AmeriPlan Health® is NOT insurance.
IBO #
health insurance or a MediCare Prescription
Drug Plan. Membership in these programs First Name MI Last Name

Member Information
entitles you to discounts for certain medical
services and prescription drugs by Date of Birth of Applicant Male/Female Residence or Work Telephone Alternate Telephone
providers who have agreed to participate in
these discount programs. These programs
do NOT make payments directly to the Mailing Address Apt.#
providers of medical services and prescription
drugs. The programs’ members are obligated City State Zip
to pay for all healthcare services, but will
receive a discount from those healthcare

Household Members
providers who have contracted with these First Name Last Name Date of Birth LIST
ADDITIONAL
discount programs. The name, address and HOUSEHOLD
MEMBERS ON A
specialty of the discount medical and SEPARATE SHEET OF
prescription drug program providers in your PAPER.

service area are available before purchase

and upon request by logging on to
E-MAIL ADDRESS
www.ameriplanusaprovidersearch.com or call
the AmeriPlan® Consumer Information Center
at 1-800-647-8421.
Total Health Plus
Dental, Vision, Prescription, Chiropractic, Physician, Ancillary, Hospital Advocacy, NurseLine, and
AmeriPlan® Corporation Podiatry Plus Non-Medical Discount Programs Auto Club, Identity Theft Assistance, Legal
5700 Democracy Drive Plano, Texas 75024
A Discount Medical Plan Organization Monthly Health Fee - $39.95 Quarterly Health Fee - $119.85 Annual Health Fee - $479.40
Non-Medical Fee - $20.00 Non-Medical Fee - $60.00 Non-Medical Fee - $240.00
The average savings on the most utilized provider procedures
stated in this brochure are only a sample from the discount fee TOTAL AMOUNT- $59.95 TOTAL AMOUNT- $179.85 TOTAL AMOUNT- $719.40
schedule that each AmeriPlan® provider has agreed to honor for
members. The discounts represent a reduction on a treatment or
percentage basis of the usual and customary fees charged by the
providers for a specific treatment. By submitting your enclosed check, you are authorizing
AmeriPlan® confirms that its medical, dental, vision, chiropractic the ongoing draft until AmeriPlan® is notified of
and pharmacy providers are professionally licensed in your state, cancellation in writing.
but does not guarantee the quality of the services or products. ®
Quality of care complaints should be addressed to the appropri- First Month Membership Fee $
ate licensing agency in your state. If you are not sure whom to I WANT TO PAY MY MONTHLY OR QUARTERLY MEMBERSHIP FEE BY: Total Monthly Fee -$59.95
call regarding quality of care complaints, contact the Consumer
Information Center at 1-800-647-8421. BANK DRAFT: Please Draft on the 3rd or 18th of the month. First Quarter Membership Fee $
Total Quarterly Fee -$179.85
If you have health insurance, this discount medical plan may be
duplicative of your health insurance. CREDIT CARD: Visa MasterCard Discover American Express Annual Membership Fee $
For more information, Card # Expiration Date Total Annual Fee -$719.40

contact AmeriPlan® IBO: One-time Registration Fee $

Total Health Plus Registration Fee $30.00re NON REFUNDABLE

X SIGNATURE FOR CREDIT CARD OR BANK DRAFT

TOTAL AMOUNT DUE $
MONTHLY OR QUARTERLY PAYMENTS MUST BE MADE BY ELECTRONIC BANK DRAFT OR BY CREDIT CARD.
INVOICING IS AVAILABLE FOR ANNUAL MEMBERSHIPS ONLY WITH FIRST YEAR PAID IN ADVANCE.
AMP017T (06/08)

Enclose your check for payment and a voided check if paying monthly or quarterly by bank draft.

DISCOUNTS ARE NOT INSURANCE Page 1 © 2008 AmeriPlan® Corporation. All rights reserved. DPR.06.08
 Example of savings
on the most utilized dental procedures:
AmeriPlan® Discount
Sample General
Dentist Procedures*
Dental Office
Fees** up to
AmeriPlan®
Fees
AmeriPlan®
Savings
Programs are
Up To
NOT INSURANCE!
D0150 - Initial Oral Exam $118 $37 69%
D0120 - Periodic Oral Exam 70 14 80%
X-Rays
D0210 - Intraoral Complete Series 162 65 60%
D1110 - Regular Teeth Cleaning
(Light Scaling & Polishing) 117 47 60%
What makes AmeriPlan Dental Plus™ Different ... and Better?
Amalgam Fillings (Silver Colored)
D2140 - 1 Surface -
Primary or Permanent 174 70 60%
Dental: The COMPLETE package !
~ MORE THAN 30,000 DENTAL PROVIDERS NATIONWIDE.
Composite Filling (Tooth Colored) ~ NO LIMIT ON VISITS OR SERVICES. Includes ALL of our Health and Dental Programs …
D2330 - 1 Surface (Anterior) 201 95 53% ~ ONGOING DENTAL PROBLEMS ARE ACCEPTED, (Except Dental and Orthodontic
Root Canal (Excluding Final Restoration)
~
treatments in progress.)
INSTANT SAVINGS.
Dental, Vision, Prescription, Chiropractic, Physician,
D3310 - Anterior 902 375 58% Ancillary Services, Hospital Advocacy,
~ NO AGE LIMIT.
D2750 - Porcelain Crown 1,365 550 60% ~ NO PAPERWORK.
(w/High Noble Metal) ~ NO WAITING PERIOD. NurseLine, and Podiatry… and More:
Orthodontic Treatment (Braces) ~ ORTHODONTICS (braces) AND COSMETIC DENTISTRY INCLUDED.
(Invisalign Braces may not be included.) ~ SPECIALISTS INCLUDED, (where available.) AmeriPlan® Auto Club
by General Dentist ~ YOU CAN CHANGE DENTISTS.
Physician: Administered by United States Auto Club-Motoring Divison
D8080 - Child (under age 19) 5,000 2,100 58% ~ NO WAITING PERIOD.
D8090 - Adult (age 19 and over) 5,500 2,250 59% Vision: Auto Club - There is nothing more frustrating than having trouble with your car while
~ MORE THAN 12,000 OPTICAL PROVIDERS NATIONWIDE. ~ NO PRE-AUTHORIZATION FOR TREATMENT REQUIRED. on the road. And if the trouble with the car isn’t enough, you sure don’t want trouble
* Current Dental Terminology © 2008 American Dental Association, All Rights Reserved. ~ SAVE FROM 20% TO 60% on all frames, lenses, tints, scratch-resistant coatings and ultra-violet ~ NO PAPERWORK. getting immediate assistance. Membership in the AmeriPlan® Auto Club program will
**National Dental Advisory Service 2008. protection. ~ INSTANT SAVINGS. give you the service, comfort and savings to lessen your bad experience. Reliable,
~ SAVE FROM 10% TO 50% on ophthalmology eye exams, and LASIK surgery with certain qualified service providers are available 24/7. The first $50.00 of emergency roadside or
Different fees may apply in different areas of your state. ~ SPECIALISTS INCLUDED, WHERE AVAILABLE. towing services will cost you nothing, just sign your name and drive away. Additional
For the appropriate fees for your area, go to providers in selected markets.
~ MOST ONGOING MEDICAL PROBLEMS ARE INCLUDED. charges are discounted by at least 25% off of the retail price. While breakdowns are
www.ameriplanusaprovidersearch.com or call 1-800-647-8421. ~ SAVE FROM 10% TO 20% ON CONTACT LENSES (excluding disposables) at participat- never fun, this program lessens the pain.
ing retail locations. ~ COSMETIC SURGERY INCLUDED, WHERE AVAILABLE.
~ SPECIAL SAVINGS FROM 10% TO 40% ON REPLACEMENT CONTACT LENSES. ~ NO AGE LIMIT.
Including daily wear, extended wear, disposable, tinted, bifocals and gas permeable.* AmeriPlan® Identity Theft Assistance
Example of savings on medical procedures in ~ ADDITIONAL DISCOUNTS on designer non-prescription sunglasses with the world’s
~ YOU CAN CHANGE PHYSICIANS. Administered by CLC

Identity Theft - Today, Identity Theft has become a $50 billion problem in the United
a general physician’s* office (family physician) largest online optical store.**
States. More and more people at all levels of society are becoming victims. What once
~ 30-DAY UNCONDITIONAL money-back guarantee on all merchandise.
and laboratory fees: ~ TOLL-FREE NUMBER to locate independent and participating chain network providers. Ancillary Services: was a problem for the wealthy has become a problem for all of us. There are two
important elements of the identity theft issue that applies to everyone. First is the
* Available through mail order program only. ** Available through Internet program only. Includes services such as physical therapy, laboratory procedures, imaging centers, matter of prevention and second is the matter of resolution after the fact. This CLC
Sample General Physician*/Lab AmeriPlan® AmeriPlan® hearing services, mental health services, and diabetic supplies. Identity Theft Program addresses both of these issues.
Physician Procedures* Fees up to** Fees Savings Prescription:
and Lab Sevices
~ OVER 56,000 PARTICIPATING RETAIL AND INDEPENDENT Hospital Advocacy: AmeriPlan® Legal
New Patient PHARMACY LOCATIONS NATIONWIDE* Should you need to be hospitalized, and the anticipated charges will exceed Administered by CLC CONSUMER HEALTH ALLIANCE
PROTECTING CONSUMER ACCESS
~ Save 10% - 85% on most brand name and generic prescription drugs** $2,500.00, an advocate will be assigned to negotiate the best possible fees for the Legal and Financial - Should you have the need to consult an attorney, this program will TO DISCOUNT HEALTHCARE PROGRAMS
Intermediate Visit $187 $112 40% ~ Save on over the counter medications, smoking cessation aids and diabetes supplies hospital services. There is a three-day waiting give you a FREE one hour initial consultation for each occurrence and a 25% discount on
Extended Visit 289 173 40% ~ Mail order pharmacy option available period from the active date of your membership to utilize this program. any ongoing legal fees. You will also have access to over 4,500 online legal documents,
~ No cost prescriptions - You may qualify for AmeriPlan's Prescription Advocacy along with a complete legal reference resource.
Established Patient Program. NurseLine U.S. Chamber of Commerce

Pharmacy discounts are NOT insurance services or a MediCare Precription At no cost you can address immediate health matters or get your health questions CONSUMER HEALTH ALLIANCE
Limited Visit 125 75 40% Drug Plan and are NOT intended as a substitue for insurance. answered by a licensed registered nurse 24/7. You may save hours lost while C H
PROTECTING CONSUMER ACCESS
TO DISCOUNT HEALTHCARE PROGRAMS
EALTH ALLIANCE

Intermediate Visit 189 114 40% * Discounts are available only at participating pharmacies.
waiting in a doctor’s office, missed time from work and even the high cost of Not Available in South Carolina ONSUMER
PROTECTING CONSUMER ACCESS
TO DISCOUNT HEALTHCARE PROGRAMS

** You may not receive a savings on some high-volume or maintenance type office visits.
drug since these medications may have already been reduced at the pharmacy level.
Member in Good Standing U.S. Chamber of Commerce
Laboratory Fees
Chiropractic: Podiatry Services:
Lipid Panel 88 11 87% ~ MORE THAN 7,500 PARTICIPATING DOCTORS. Foot and ankle specialists provide comprehensive management, through medical U.S. Chamber of Commerce
(Cholesterol, HDL, LDL, Triglycerides) or surgical methods, of a wide variety of problems that affect foot and ankle
~ FREE INITIAL CONSULTATION. CONSUMER HEALTH ALLIANCE
function. PROTECTING CONSUMER ACCESS
CBC (Complete Blood Count) 37 14 62% ~ 50% SAVINGS on all diagnostic services & required x-rays. TO DISCOUNT HEALTHCARE PROGRAMS

* Specialists’ fees will be slightly higher. ~ 30% SAVINGS on treatment and most other services.
** Physicians fee reference 2008. ~ NO LIMIT on number of visits.
Different fees may apply in different areas of your state. ~ TOLL-FREE NUMBER to locate participating network chiropractors.
 Example of savings
on the most utilized dental procedures:
AmeriPlan® Discount
Sample General
Dentist Procedures*
Dental Office
Fees** up to
AmeriPlan®
Fees
AmeriPlan®
Savings
Programs are
Up To
NOT INSURANCE!
D0150 - Initial Oral Exam $118 $37 69%
D0120 - Periodic Oral Exam 70 14 80%
X-Rays
D0210 - Intraoral Complete Series 162 65 60%
D1110 - Regular Teeth Cleaning
(Light Scaling & Polishing) 117 47 60%
What makes AmeriPlan Dental Plus™ Different ... and Better?
Amalgam Fillings (Silver Colored)
D2140 - 1 Surface -
Primary or Permanent 174 70 60%
Dental: The COMPLETE package !
~ MORE THAN 30,000 DENTAL PROVIDERS NATIONWIDE.
Composite Filling (Tooth Colored) ~ NO LIMIT ON VISITS OR SERVICES. Includes ALL of our Health and Dental Programs …
D2330 - 1 Surface (Anterior) 201 95 53% ~ ONGOING DENTAL PROBLEMS ARE ACCEPTED, (Except Dental and Orthodontic
Root Canal (Excluding Final Restoration)
~
treatments in progress.)
INSTANT SAVINGS.
Dental, Vision, Prescription, Chiropractic, Physician,
D3310 - Anterior 902 375 58% Ancillary Services, Hospital Advocacy,
~ NO AGE LIMIT.
D2750 - Porcelain Crown 1,365 550 60% ~ NO PAPERWORK.
(w/High Noble Metal) ~ NO WAITING PERIOD. NurseLine, and Podiatry… and More:
Orthodontic Treatment (Braces) ~ ORTHODONTICS (braces) AND COSMETIC DENTISTRY INCLUDED.
(Invisalign Braces may not be included.) ~ SPECIALISTS INCLUDED, (where available.) AmeriPlan® Auto Club
by General Dentist ~ YOU CAN CHANGE DENTISTS.
Physician: Administered by United States Auto Club-Motoring Divison
D8080 - Child (under age 19) 5,000 2,100 58% ~ NO WAITING PERIOD.
D8090 - Adult (age 19 and over) 5,500 2,250 59% Vision: Auto Club - There is nothing more frustrating than having trouble with your car while
~ MORE THAN 12,000 OPTICAL PROVIDERS NATIONWIDE. ~ NO PRE-AUTHORIZATION FOR TREATMENT REQUIRED. on the road. And if the trouble with the car isn’t enough, you sure don’t want trouble
* Current Dental Terminology © 2008 American Dental Association, All Rights Reserved. ~ SAVE FROM 20% TO 60% on all frames, lenses, tints, scratch-resistant coatings and ultra-violet ~ NO PAPERWORK. getting immediate assistance. Membership in the AmeriPlan® Auto Club program will
**National Dental Advisory Service 2008. protection. ~ INSTANT SAVINGS. give you the service, comfort and savings to lessen your bad experience. Reliable,
~ SAVE FROM 10% TO 50% on ophthalmology eye exams, and LASIK surgery with certain qualified service providers are available 24/7. The first $50.00 of emergency roadside or
Different fees may apply in different areas of your state. ~ SPECIALISTS INCLUDED, WHERE AVAILABLE. towing services will cost you nothing, just sign your name and drive away. Additional
For the appropriate fees for your area, go to providers in selected markets.
~ MOST ONGOING MEDICAL PROBLEMS ARE INCLUDED. charges are discounted by at least 25% off of the retail price. While breakdowns are
www.ameriplanusaprovidersearch.com or call 1-800-647-8421. ~ SAVE FROM 10% TO 20% ON CONTACT LENSES (excluding disposables) at participat- never fun, this program lessens the pain.
ing retail locations. ~ COSMETIC SURGERY INCLUDED, WHERE AVAILABLE.
~ SPECIAL SAVINGS FROM 10% TO 40% ON REPLACEMENT CONTACT LENSES. ~ NO AGE LIMIT.
Including daily wear, extended wear, disposable, tinted, bifocals and gas permeable.* AmeriPlan® Identity Theft Assistance
Example of savings on medical procedures in ~ ADDITIONAL DISCOUNTS on designer non-prescription sunglasses with the world’s
~ YOU CAN CHANGE PHYSICIANS. Administered by CLC

Identity Theft - Today, Identity Theft has become a $50 billion problem in the United
a general physician’s* office (family physician) largest online optical store.**
States. More and more people at all levels of society are becoming victims. What once
~ 30-DAY UNCONDITIONAL money-back guarantee on all merchandise.
and laboratory fees: ~ TOLL-FREE NUMBER to locate independent and participating chain network providers. Ancillary Services: was a problem for the wealthy has become a problem for all of us. There are two
important elements of the identity theft issue that applies to everyone. First is the
* Available through mail order program only. ** Available through Internet program only. Includes services such as physical therapy, laboratory procedures, imaging centers, matter of prevention and second is the matter of resolution after the fact. This CLC
Sample General Physician*/Lab AmeriPlan® AmeriPlan® hearing services, mental health services, and diabetic supplies. Identity Theft Program addresses both of these issues.
Physician Procedures* Fees up to** Fees Savings Prescription:
and Lab Sevices
~ OVER 56,000 PARTICIPATING RETAIL AND INDEPENDENT Hospital Advocacy: AmeriPlan® Legal
New Patient PHARMACY LOCATIONS NATIONWIDE* Should you need to be hospitalized, and the anticipated charges will exceed Administered by CLC CONSUMER HEALTH ALLIANCE
PROTECTING CONSUMER ACCESS
~ Save 10% - 85% on most brand name and generic prescription drugs** $2,500.00, an advocate will be assigned to negotiate the best possible fees for the Legal and Financial - Should you have the need to consult an attorney, this program will TO DISCOUNT HEALTHCARE PROGRAMS
Intermediate Visit $187 $112 40% ~ Save on over the counter medications, smoking cessation aids and diabetes supplies hospital services. There is a three-day waiting give you a FREE one hour initial consultation for each occurrence and a 25% discount on
Extended Visit 289 173 40% ~ Mail order pharmacy option available period from the active date of your membership to utilize this program. any ongoing legal fees. You will also have access to over 4,500 online legal documents,
~ No cost prescriptions - You may qualify for AmeriPlan's Prescription Advocacy along with a complete legal reference resource.
Established Patient Program. NurseLine U.S. Chamber of Commerce

Pharmacy discounts are NOT insurance services or a MediCare Precription At no cost you can address immediate health matters or get your health questions CONSUMER HEALTH ALLIANCE
Limited Visit 125 75 40% Drug Plan and are NOT intended as a substitue for insurance. answered by a licensed registered nurse 24/7. You may save hours lost while C H
PROTECTING CONSUMER ACCESS
TO DISCOUNT HEALTHCARE PROGRAMS
EALTH ALLIANCE

Intermediate Visit 189 114 40% * Discounts are available only at participating pharmacies.
waiting in a doctor’s office, missed time from work and even the high cost of Not Available in South Carolina ONSUMER
PROTECTING CONSUMER ACCESS
TO DISCOUNT HEALTHCARE PROGRAMS

** You may not receive a savings on some high-volume or maintenance type office visits.
drug since these medications may have already been reduced at the pharmacy level.
Member in Good Standing U.S. Chamber of Commerce
Laboratory Fees
Chiropractic: Podiatry Services:
Lipid Panel 88 11 87% ~ MORE THAN 7,500 PARTICIPATING DOCTORS. Foot and ankle specialists provide comprehensive management, through medical U.S. Chamber of Commerce
(Cholesterol, HDL, LDL, Triglycerides) or surgical methods, of a wide variety of problems that affect foot and ankle
~ FREE INITIAL CONSULTATION. CONSUMER HEALTH ALLIANCE
function. PROTECTING CONSUMER ACCESS
CBC (Complete Blood Count) 37 14 62% ~ 50% SAVINGS on all diagnostic services & required x-rays. TO DISCOUNT HEALTHCARE PROGRAMS

* Specialists’ fees will be slightly higher. ~ 30% SAVINGS on treatment and most other services.
** Physicians fee reference 2008. ~ NO LIMIT on number of visits.
Different fees may apply in different areas of your state. ~ TOLL-FREE NUMBER to locate participating network chiropractors.