FAMILY MEDICAL MANAGEMENT
Discounted Medical Plan where your health is our #1 priority
Call (215)669-3722 
email:
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Printable Enrollment Form                   HomeAbout FMMCoverageFAQsEnrollLocations

Family Medical Services Plan Registration Form

 

Name___________________________________________________

Plan Membership Number_________________

 

Membership type: Please circle the appropriate membership and fill out the names of the members.

 

One-Person Membership

Name: __________________

 

Two-Person membership

Name: __________________


Name: __________________

 

Family Membership

Please note that in order to qualify for a family membership for a fee of $15 a month, there must be no greater than five (5) members in the family: a maximum of two (2) adults and three (3) dependent children. If you wish to include more than three (3) dependent children within the Family Membership, you must pay $150 a month PLUS an additional amount of $35 each month for each additional dependent child.

 

Name of Adult #1: ___________________________________

Name of Adult #2: ___________________________________


Name of Dependent Child #1:  __________________________


Name of Dependent Child # 2: __________________________


Name of Dependent Child #3 : __________________________


Name of Additional Dependent Child:  ____________________


Name of Additional Dependent Child:   ____________________


Name of Additional Dependent Child:  ____________________

 

 

I acknowledge that I have read the terms and conditions of the Family Medical Services Plan and agree to be bound by them on behalf of myself and each other member listed above.

 

Signature____________________________

       
      
Date____________________________