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Discount Medical Plan Application

FORM #DBI001

Your membership is effective upon receipt of membership materials.

This is NOT insurance nor is it intended to replace insurance. This discount card program contains a 30 day cancellation period. The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CMR 5.00. This plan provides discounts at certain healthcare 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 healthcare services but will receive a discount from those healthcare providers who have contracted with the discount plan organization. For a full list of disclosures, please click here. | Terms and Conditions | Discount Medical Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box 671309, Dallas, TX 75367-1309.

© 2016 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are registered trademarks of Teladoc, Inc. and may not be used without written permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation; phone and/or video consultations may not be available in certain states. Consults are not available outside of the U.S. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. Teladoc phone consultations are available 24 hours, 7 days a week while video consultations are available during the hours of 7am to 9pm, 7 days a week. Teladoc operates subject to state regulation. Click here to view a Teladoc Access Map

Dental Benefit is not available to VT residents.

The discount program provides access to the Aetna Dental Access® network. This network is administered by Aetna Life Insurance Company (ALIC). Neither ALIC nor any of its affiliates offers or administers the discount program. Neither ALIC nor any of its affiliates is an affiliate, agent, representative or employee of discount program. Dental providers are independent contractors and not employees or agents of ALIC or its affiliates. ALIC does not provide dental care or treatment and is not responsible for outcomes.

Lab benefit not available to HI, MA, MD, ND, NJ, NY, RI or SD residents.

Not available to UT, KS, VT or WA residents. AR and TN residents: A refund of all fees will be issued if membership is cancelled within the first 30 days.