PERSONAL INFORMATION

Address

APPLICANT’S INFORMATION AND PRIMARY CARE PHYSICIANS (PCP) SELECTION

Primary

Dependent 1

Dependent 2

Dependent 3

PAYMENT METHOD

Expiration Date (Month/Year)

The term of this agreement is on a month-to-month basis. Member may cancel at any time with a thirty (30) day advance written notice. To cancel this membership, mail or deliver a signed written notice with the reason to: ProMedical Plan PHC, Inc. 400 Sawgrass Corporate Parkway Suite #200 Sunrise, FL 33325