MEMBERSHIP APPLICATION

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Individual Membership

From: $40.00 for 1 year with a 5-day activation period

This membership is available for a one year membership coverage. At the end of your membership coverage period, your membership will auto-renew. If you need to change your payment information or disable auto-renew, you can change this at any time under “My Account.”

Please select your current health insurance status, then complete the additional information below.

Health insurance status?

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Are you a renewing member? Enter your membership ID. (optional)

Mailing Address *

Mailing State *

Mailing City *

Mailing Zip Code *

Phone *

Email *

Resident 1: First Name & Middle Initial *

Resident 1: Last Name *

Resident 1: Date of Birth *

Resident 1: Have insurance? * Yes No

Referred by (optional)

PHI Employee ID (optional)

Base Code (optional)