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Member Agreement


MEMBER PARTICIPATION AGREEMENT


As a member of [Plan or Program] you are a participant in a Discount Medical Program (DMP) provided by AccessOne Consumer Health, Inc.  Below are the terms and conditions of your membership in the AccessOne discount medical plan. This agreement is between you and AccessOne.
 
This Membership Agreement is effective as of [        ] and shall continue from month to month until AccessOne is notified of your cancellation.
 
The Monthly Charge for participation in the program is: $ [        ]
 
The One Time Non-Refundable Processing Fee is: $ [        ]
 

 
DISCLOSURES:
  • This is not an insurance policy;
  • Discounts are provided at certain healthcare providers for healthcare services;
  • AccessOne does not make payments directly to the providers of healthcare services;
  • You are obligated to pay for all healthcare services but will receive a discount from healthcare providers who have contracted with Accessone;
  • The discount medical plan organization you are joining is: AccessOne Consumer Health 84 Villa Road, Greenville SC 29615 www.accessonedmpo.com
You may find a list of participating providers at: www.accessonedmpo.com or you may call: 800-896-1962. You will be able to apply plan discounts to all participating providers of each participating network.
 
This plan includes discounts for: [Discounts Selected]
 
The included Benefit Description(s) describe the type and extent of the discounts available under the plan. The minimum discount for any service provided under the plan is 5% and may go to as much as 50%. The Benefit Description(s) becomes part of this Membership Agreement.
 
You will be billed at the time of service by the participating provider who will apply the applicable discounts to that bill. In no instance can AccessOne make payments directly to the provider on your behalf.
 
 Your participation in the plan will continue from month to month upon payment of your monthly dues and shall cease upon (i) your failure to make the monthly payment; or (ii) notification in writing (USPS, email or facsimile) of you desire to cancel.
 
You have the right to cancel participation in the program at any time. If you do so within 30 days of receipt of your membership materials you will receive a full refund of all fees and or dues paid to participate in this DMP.
 
AccessOne may terminate your participation in the program if you fail to make your membership payment when due.
 
This program includes all members of your household (you your spouse and legal dependants). You are not required to list your dependants to participate in the plan. You may add dependants or additional members of your household by calling AccessOne at 800-896-1962.
 
If you have a complaint regarding the plan you may go to www.accessonedmpo.com or call 800-896-1962. You may also write to AccessOne Consumer Health, Inc. 84 Villa Rd. Greenville, SC 29615. The complaint will be addressed and you will receive a response within 15 days.
 
This Agreement and its Benefit Descriptions represent the entire agreement between you and AccessOne Consumer Health, Inc. and supersede all other prior representations, statements, or written agreements between you and AccessOne. 

                                                                   
                                                       
 Member Name     
 Member Signature

                                                       
                                                       
 Member Signature  
 Date

                                                       
                                                       
 Member Street Address
 Member City, State, Zip

                                                       
                                                       
 Member E-Mail  
 Member Telephone