ORDER PROCESSING




Upon submission of this secured form, Aegis Administrative Services Inc. will charge your credit card for the Tricare-Healthpack Discount program.
This Program Is NOT INSURANCE.
Please complete the form fully to insure the proper charge to your account.

Thank you for using our online services.

* - Required Fields

1. Select your payment plan*
Discount Pharmacy, AetnaDental Access(sm), 24 HOUR Health Information Network, Vision & Contact Lens Program

Monthly Charge (minimum 2 months)

$24.95 per month

$54.90 (Initial 2 Months)

$24.95 per month after initial 2 month startup.

2. Customer billing information
First Name:*  
Last Name:*  
Company Name:  
Date of Birth:*  
Sex:*  
Telephone:*  
Street Address:*  
City:*  
State:*  
Zip:*  
     
Shipping Address
(if different):		  
Shipping First Name:*  
Shipping Last Name:*  
City:  
State:  
Zip:  
Email:*  
   
3. Credit Card Information  
Accepted Cards: Visa, MasterCard, American Express, Discover
Card Number:* (enter number without spaces)
Expiration Date:* (MMYY)
Card Code:*  
   
4. Complete if spouse and/or children are included.
Spouse's Name: Date of Birth
Child's Name: Date of Birth
Child's Name: Date of Birth
Child's Name: Date of Birth
Child's Name: Date of Birth
Child's Name: Date of Birth
Child's Name: Date of Birth
   
5. Signatures  
Applicants
Signature:*		 Typing your signature and confirming your signature authorizes release of your information and enrollment into the program. The enrollment kit is sent via mail.
Applicants
Signature: (Confirm)*