PIONEER ENROLLMENT FORM

Minor medical coverage for everyday emergencies for
$100/YEAR/adult; $175/YEAR/couple and $50/YEAR/child (under 18).
5% Equal Dollars accepted.

I agree that my pioneer membership payment shall be placed into an account at a Philadelphia credit union and that payments for minor medical expenses shall begin and expand at least at the rate seen at progress.html.
I understand that this Alliance is not a major medical plan. It covers only the categories listed at progress.html, to the maximum amounts specified."
I understand that I will be eligible for payments anywhere in the world with any health provider for these specified health needs.
I understand that PhilaHealthia does not yet provide a legal contract to pay for medical needs but will put all grants and denials of grants on its website.
I agree that PhilaHealthia shall be governed by bylaws found at healthdemocracy.org/bylaws

NAME/S __________________________________________________________________

ADDRESS: _________________________________ CITY _______________ STATE ___ ZIP ______

EMAIL ______________________________________ PHONE __________________________
(you will be notified by email whenever the number of new members enlarges your coverage)

PRIMARY HEALTH INSURER IF ANY ___________________________________________

HEALTH SERVICE TYPE IF OFFERING DISCOUNT ________________________________
DISCOUNT OFFERED ___%
WEBSITE IF OFFERING DISCOUNT ________________________________________

____ I would like to be contacted about serving on the board of directors.

DONATION $__________ (to enroll low-income person)

MAIL TO:
check to: PhilaHealthia
700 Carpenter Lane
Philadelphia, PA 19119

QUESTIONS? (215) 805-8330 paul5glover@yahoo.com

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