Discount Medical Plan Application
PRODUCTS INCLUDED: LASIK VISION CORRECTION,MEDICAL INFORMATION,VISION,PRESCRIPTION,DENTAL
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Step 1: Billing Options

Select a billing option:
 
Member Only
/Month
/Year
Member Plus Spouse
/Month
/Year
Member Plus Family
/Month
/Year

*Plus a one-time non-refundable processing fee of $20.00


 
$12.95 billed monthly + $20.00 one time non-refundable processing fee


Total = $32.95 will be charged for your first month, $12.95 will be charged monthly thereafter


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FORM CODE CICONLINEAPP


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