Member Agreement for Discount Medical Plan(s)

Disclosures: This discount plan is not health insurance. The plan provides discounts at certain health care providers for medical services. The Plan does not make payments directly to providers of medical services. Members are obligated to pay for all health care services at the time the services are performed, but will receive a discount from contracted providers. The Discount Medical Plan Organization is Patriot Health Florida, Inc., located at 160 Eileen Way, Syosset, NY 11791. To obtain additional information and an up-to-date list of contracted providers by name, city, state, and specialty in your service area, you may call customer service 1-(800) 292-3797 or click here . This Plan is not available in all states. Plan administrators have no liability for providing or guaranteeing service or for the quality of service rendered. Participating providers are subject to change without notice and are not available in all areas.

1. Entire Agreement: All provisions under this Agreement, ID card, Application and product descriptions constitute the entire Agreement between the Company and the Member. This contract is not protected by any state Life and Health Guaranty Association. Discounts on professional services are not available where prohibited by law.
2. Tiered Dental Plan Monthly rates: $12.88 Individual $15.88 Individual + Spouse or Child $18.88 Family
   Tiered Dental Plan Annual rates: $139.10 Individual $171.50 Individual + Spouse or Child $203.90 Family
   Tiered Dental/Vision Plan Monthly rates: $14.88 Individual $17.88 Individual + Spouse or Child $19.88 Family
   Tiered Dental/vision Plan Annual rates: $160.70 Individual $193.10 Individual + Spouse or Child $214.70 Family
   PLUS Plan Monthly rates: $19.88 Individual $24.88 Individual + Spouse or Child $29.88 Family
   PLUS Plan Annual rates: $214.70 Individual $268.70 Individual + Spouse or Child $322.70 Family
   PREMIER Plan Monthly rates: $29.88 Individual $39.88 Individual + Spouse or Child $49.88 Family
   PREMIER Plan Annual rates: $322.70 Individual $430.70 Individual + Spouse or Child $538.70 Family
3. Adding New Members: Under the family plan, you may add family members by calling the customer service number. Under the family plan no activation or other fee will be applied for adding new family members. However, if you are upgrading your plan from individual to plus one or family your monthly fee will reflect this change.
4. Cancellation: If you are not completely satisfied, you may call 1-800 292-3797 to cancel at any time. If you cancel within the first 30 days, your membership fee will be refunded. The one time member activation fee is non-refundable, except where refund provisions for such are specified by state law. If you cancel, your membership will terminate at the end of the billing cycle for which you have paid. After you have called to cancel, you will need to provide a written letter verifying that you cancelled the plan, including your member ID#, and an original signature. You can send the letter either via fax to the attention of the Cancellation Department FAX: 516-576-9268 or via US Mail to Cancellation Department 160 Eileen Way, Syosset NY 11791. Call to verify that your cancelation letter has been received. Upon receipt of written cancellation, your membership will terminate and you will not be billed further for any discount medical plans. If the discount medical plan cancels membership for any reason other than nonpayment of charges, the discount medical plan shall make a pro rata reimbursement of all periodic charges to you. For FL residents: If you cancel your membership within the first 30 days after the effective date of enrollment in the plan, you will receive a reimbursement of all periodic charges upon return of the discount card to us. If you cancel your membership for any reason other than nonpayment, we will make a pro rata reimbursement of all periodic charges to you. Note to residents of OK: If you decide to cancel the membership within the first thirty (30) days after receipt of this membership kit, you will receive a reimbursement of all periodic charges paid. The return of all periodic charges shall be made within thirty (30) days of the date of the cancellation. If all of the periodic charges have not been paid within thirty (30) days, interest shall be assessed and paid on the proceeds at a rate of the Treasury Bill rate of the preceding calendar year, plus two (2) percentage points.
5. Best Efforts: The Company shall use its best efforts to obtain acceptance from an adequate number of Providers who will agree to provide Eligible Services to Members. The final selection of the medical professional and/or medical facility and the approval or disapproval of medical treatment is the Member’s choice alone.
6. Member Card: Member will be provided with a Membership Card. Such card and other forms of identification should be carried by the Member at all times to provide proof of the right to Eligible Services under the Membership Agreement. The discounts contained herein may not be used in conjunction with any other discount plan or Plan. All listed or quoted prices are current prices from participating providers and subject to change without notice. From time to time, certain providers may offer products and/or services to the general public at prices lower than the discounted prices available through this Plan. In such event, members will be charged the lowest price. Plan may not be available or vary in some states.

Note to Texas Consumers: Regulated by the Texas Department of Licensing and Regulation, P.O. Box 12157, Austin, Texas 78711; telephone 1-800-803-9202 or (512) 463-6599; website: www.license.state.tx.us/complaints. Note to Illinois Consumers: To file a complaint with the Illinois Department of Insurance please contact 866 445-5364.

THIS PLAN IS NOT INSURANCE and is not intended to replace health insurance. This plan does not meet the minimum creditable coverage requirements under M.G.L. c. 111M and 956 CMR 5.00. This plan is not a Qualified Health Plan under the Affordable Care Act.

T&C-103-112008