Sign Up | American Health Options

Discount Medical Plan Application

Your Transaction Number is:

Your Member # will be available within in 2 business days.

Payment Cycle

Member Information

First Name:	Last Name:
E-mail Address:	Phone Number:
Gender:	Date of Birth:

Billing Address

Billing Address:		Apt/ Suite # (optional):
City:
State:	ZIP:
Shipping address
Shipping Address is the same as Billing Address
Shipping Address:		Apt/ Suite # (optional):
City:
State:	ZIP:

Dependents information

Number of dependents:

Payment Type:

Card

Check

Credit Card or Check Card Payment

Name on Card:

Card number:	CVV Security Code:

Expiration Date:

CVV Sample

Visa / MasterCard / Discover

Your card security code for your Visa, MasterCard or Dicover card is a three-digit number on the back of your credit card, immediately following your main card number.

American Express

The card security code for your American Express card is a four-digit number located on the front of your credit card, to the right or left above your main credit card number.

I agree to Terms of Membership

Need Assistance?

Call to speak with a Our representative

866-387-3880

This is the sign-up at $ a month.

Benefits Included in this Plan

Plan Summary

Plan Cost:

$ / Year

One-time Registration Fee:

Total Cost:

$0.00

30-Day Money Back Guarantee

If you are not fully satisfied in the first 30 days, we will refund your first month's payment or annual fee minus the one-time non-refundable registration fee.

Why Us

Risk-Free. 100% satisfaction guaranteed.
Exclusive members-only savings on all dental procedures. Low pre-negotiated rates.
Easy to Use. Hassle-Free.
Immediate activation. No hidden cost.

What Our Members Are Saying

When I lost my job in 2012 and have been without dental benefits since. I jumped on the their website, found my dental office, and went in fully loaded with info. They presented me with a list of services with discounted prices. 55% SAVINGS. I could have been out several thousand dollars compared to what I will currently be paying in dental benefits thanks to them!

Jimmie, Freeland PA

1 Your plan will be active on Thursday, May 23, 2013 if you join today.

A $25 one-time application fee will be added during checkout.

2 Family members include card holder, spouse, and legal dependents up to the age of 18 or up to

to age of 25 as long as they are full time students.

American Health Options

Discount Medical Plan Application

Member Information

Billing Address

Dependents information

Credit Card or Check Card Payment

Electronic Check Payment

Terms & Conditions

Account name:
Routing number:	Account number: