The Outlook Prescription Plan Discount Program Application

Discount Prescription Plan Membership:

 $19.95

First Month Free Promo:

 -19.95

One-Time Setup and fulfillment fee:

 $19.95

Total Charges:

 $19.95

Membership Benefits: physician/hospital care, neighborhood pharmacy, mail order pharmacy, dental, vision, chiropractic care, hearing benefit, phone-a-doc, nurse assistance, VIP health & wellness, diabetic supplies, family consultation, medical record storage and fitness advantage.

Membership Information                                         Shipping address same as billing address:

Billing Address

Shipping Address
First Name:   First Name:  
Last Name:   Last Name:  
Home Phone:   - - Home Phone:   - -

Work Phone:  

- -

Work Phone:  

- -
Address 1:   Address 1:  

Address 2:  

Address 2:  
City:   City:  
State or Province:   State or Province:  
ZIP code:   ZIP code:  

DOB:  

   
Gender:      
Email Address:  

Print materials in:

 English Spanish

Do You Need Dependent Cards?* YES NO              *First Dependent card is free, each additional $2.50
* The Family Plan comes with two sets of cards, one for the Primary Card Holder, and one for an additional dependent such as a Spouse. Although additional cards are not necessary and all dependents can use the Primary's membership card, additional sets can be printed for a one-time fee of $2.50. If you would like additional cards for a one-time charge, please add the dependent names below.
Dependent 1: (free)
First Name
Middle Int.
Last Name
Dependent 2:
First Name
Middle Int.
Last Name
Dependent 3:
First Name
Middle Int.
Last Name
Dependent 4:
First Name
Middle Int.
Last Name
Payment Options 100% Secure Server

Credit OR Debit Card

Checking OR Savings

      Card Type:

Cardholder Name:

Card Number:

CVV2:

   What is CVV2?

Exp. Date:

 

Checking or Savings?

Routing Number:


Where is this located?

Account Number:

 

By submitting your order, you agree to the Terms of Use as set forth by this website.  Outlook Health does NOT sell your personal information.  This Plan is NOT INSURANCE and is not available in South Dakota.
 

© 2005 Outlook Health is a subsidiary of Outlook Holding Group,  A Financial Services Organization                Terms of Use

This is not Insurance. Each Outlook Healthcare Discount Plan provide discounts at certain healthcare providers for medical services. The healthcare discount plans do not make payments directly to the providers of medical services. Each 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. This healthcare discount card program contains a 30 day cancellation period. Discount Medical Plan Organization: Newbn, Inc. 14240 Proton Rd. Dallas, TX. 75244

Form #07302005