Add Another Child's Information (If Present Optional)
Payment Information to be provided if your plan is not payroll deduct
Monthly payment is always processed in advanced on the 25th of each month. Initial payment will
be secured within 72 hours of enrollment. If payment is not received on the date billed a letter
is sent to the cardholder advising we are unable to collect payment and they must contact our office.
If payment is not received by the last date of the month the cardholder will become inactive until the
account is brought current. A notice of termination is sent to the cardholder. Cardholders have 60 days
to reinstate the benefits with payment. The information and description are not intended to be complete
description of all terms, exclusions, and conditions applicable to the products and services. The specific
rates terms and conditions of benefits will be based on actual program selected. A one-time fee of $2.00 for
processing and fulfillment will be add to your first payment.