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This simple DISCOUNT MEDICAL PLAN APPLICATION is backed by a 30-DAY MONEY BACK GUARANTEE.

If you are not completely satisfied, cancel within 30 days and we will fully refund your $14.95 membership fee*. It’s as simple as that!
Please complete this form to sign up for the HelpCare Plus Discount Medical Plan!
* Required fields.
*First Name
*Last Name
*Address 1
  Address 2
*City
*State
*Zip
*Phone () -
*Credit card #
*Name On Card
*Expiration Date
*E-mail Address
*Re-enter E-mail
  Promo Code
Offer details: I hereby apply for membership in the HelpCare Plus Plan, the $14.95 monthly membership fee will be billed automatically each month to the credit card account listed above for as long as I wish to remain a member. I am providing the information on this form directly to the HelpCare Plus plan to activate my membership. This authorization shall remain in effect until I cancel by calling the toll-free customer service number.

Administered by Coverdell & Company, Inc. (a discount medical plan organization)

Thank You!

Your Enrollment Application has been received.

You can expect to hear from a representative within 3-5 business days.