Enroll Now

Enroll Now
To enroll, fill out this form and press the submit button at the bottom of this page. Your card will be mailed to you within 10 working days. . If you are sending a check, please send to Master Healthcare: 537 Newport Center Drive, #620, Newport Beach, CA 92660 – FAX (949) 644-6762 .

Personal Information
Please fill in all fields that apply

* Member First Name:

Member Last Name:

Member Middle Name:

Social Security:

Gender / Sex:

Birth Date:

Street Address:

City, State and Zip:

Day Phone:

Evening Phone:

Fax Number:

* Email Address:

Rep I.D. Number:

Sponsor:

Programs and payment Options


	Pharmacy Program


	$69 Annual


	$35 Semi-Annual


	$18 Quarterly


	$6 Monthly


	Pharmacy / Vision / Hearing Program


	$89 Annual


	$45 Semi-Annual


	$24 Quarterly


	$8 Monthly


	Doctor / Vision / Dental / Pharmacy / Hearing / Chiropractic


	$149 Annual


	$78 Semi-Annual


	$40 Quarterly


	$14 Monthly


	Yes, I would like additional cards for my family ($2.00 per card.)


	Number of addtional cards:

ALL NEW MEMBERS MUST READ AND CHECK BELOW:
I understand that the Master Healthcare Program is not an insurance program and that I am responsible for paying the medical providers at the time of service for all care received. I also understand that the Master Healthcare Program or networks accessed are not responsible for the outcome of the medical care I receive or the ultimate cost of the care.


	Yes, I have read, understand and argee with the statment above

Payment :
(Checks or money order are accepted only for annual payments)


	Automated Bank Draft:


	Account Number:


	Credit Card


	Visa


	Master Card


	American Express


	Discover


	Credit Card Number:


	Expiration Date: [mm/yy]


	Name on Card:

Billing Cycle


	Monthly


	Quarterly


	Semi-Anually


	Annually


	I authorize Master Health Care to debit my bank account or charge my credit card on the 5^th day of the month for the selected membership amount.


Dependents

	Spouse, children up to age 25, parents in household over age 60 and any other IRS dependents.


	1.

Name: [First, Middle, Last]


	Sex:


	Date of Birth:


	Full Address:


	Relationship:


	2.

Name: [First, Middle, Last]


	Sex:


	Date of Birth:


	Full Address:


	Relationship:


	3.


	Name: [First, Middle, Last]


	Sex:


	Date of Birth:


	Full Address:


	Relationship: