AUTHORIZATION

I understand that I am entitled to certain benefits and discounts that dues are required to be paid in order to maintain my membership. I understand that (1) the discount medical plan is NOT INSURANCE and is not intended to replace or be a substitute for existing insurance; and (2) membership includes certain group limited supplemental insured benefits. Dental, vision and hearing discounts are NOT insurance. Members will receive discounts on services when they go to certain health care providers who are contracted with the plan. Members are solely responsible for payment of all health care services. No portion of any of these providers’ fees will be reimbursed or otherwise paid by the plan. These services are provided through OptumHealth Allies, 505 N. Brand Blvd, Suite 850, Glendale, CA 91203.

I understand that by submitting an application for membership and completing the recorded telephone verification of application, I am agreeing to the monthly payment and the one-time fee of $25.00. I understand that if for any reason I am not issued this program or withdraw this application prior to issuance of membership materials, I will be refunded all fees paid when I submitted my application.

1. Please note that THIS IS NOT INSURANCE.
2. The plan provides discounts at certain health care providers for medical services.
3. The plan does not make payments directly to the provider of medical services.
4. Plan members are obligated to pay for all health care services but will receive a discount from those healthcare providers who have contracted with the discount medical plan organization.