Select*IndividualIndividual + 1FamilyPrimary ApplicantFirst Name*Last Name*Middle InitialGender*MaleFemaleDay Phone*Evening PhoneFaxEmail* Address*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificState / Province / RegionZip*Please enter a value between 90000 and 95899.Social Security Number*Birthday (MM/DD/YYYY)* Effective Date* Primary Care Dentist ID NumberEnter your first choice of Dental Office Number (Search for Provider Number )Type of plan(s) You're Applying For?*Low OptionMid-OptionHigh-OptionIndividual DPPONot sure which one to choose? View Plan InformationFamily First Name Last Name Middle Name Relationship Social Security Number Date of Birth Insurance Status Gender Primary Care Dentist ID Number Existing Patient  EditDelete There are no Spouse/Dependents. Add Spouse/Dependents Spouse OR DependentFirst Name*Last Name*Middle InitialSocial Security Number*Date of Birth* Insurance Status*AddCancelGender*MaleFemalePrimary Care Dentist ID NumberEnter your first choice of Dental Office Number (Search for Provider Number )Existing Patient*YesNo Individual Price: $0.00 Individual + 1 Price: $0.00 Family Price: $0.00 Enrollment fee* Price: $10.00 Total $0.00 I hereby apply for non-voting associate membership in American Association for Quality Health Care (AAQHC) and participation in the AAQHC benefit programs. I UNDERSTAND THAT:*1. Premium notices will be emailed to the address entered above.2. Coverage of the various programs may terminate for failure to pay membership dues required by AAQHC, An Administrator.3. Misrepresentation or omission in answering any part of the application may result in the cancellation of my membership, and I agree to pay for any and all services arising from the misrepresentation or omission.4. As a member, I will receive the Membership Benefits package and may be eligible for optional programs available through AAQHC.5. There is a one-time enrollment fee of $10.00 payable with the application.6. The monthly membership dues are $6.00 per month, beginning the second month of coverage.7. All membership dues are non-refundable.8. The effective date for coverage is the first of the month only. Policies cannot be prorated for cancellations or enrollments.9. The monthly payment for AAQHC membership and any optional benefits must be received in the office of AAQHC, An Administrator, by the 15th of the month preceding the benefit period. Failure to make the monthly payment may cause all AAQHC benefits to terminate. The member is responsible for payment even if premium statement is not received. A $5.00 reinstatement charge will be assessed for all cancelled policies.10. Returned payments will be assessed a $25.00 service charge and are subject to late charges.11. I may subsequently terminate my membership with a thirty (30) days' prior written notice to AAQHC, An Administrator, and have no obligation except that which accrued during the time of my membership. If I terminate my membership entirely or if I terminate the dental benefits portion of my membership only, I acknowledge that I will not be eligible to re-apply to AAQHC, An Administrator, for dental benefits for one year from the date of termination.12. All applications must be received in the office of AAQHC, An Administrator, by the 15th of the month preceding a benefit period (coverage month) in order to be considered for that benefit period. The effective date is always the first of the month following approval of application by the underwriter.13. It is my responsibility to keep AAQHC, An Administrator, apprised of any change in status as it affects state or federal laws or regulations. AAQHC, An Administrator 26050 Mureau Road, Suite 220 Calabasas, California 91302 (818) 591-8700 • FAX (818) 591-8722 (800) 669-8700 • www.aaqhc.com14. AAQHC, An Administrator, reserves the right to deny any application.15. AAQHC, An Administrator, has the authority to execute all policies and agreements with providers chosen to provide benefits in accordance with any applicable federal and state law.16. It is understood that AAQHC, An Administrator, and its related entities uses binding arbitration to settle all disputes with its members, including claims of medical malpractice and disputes relating to the delivery of service under the plan. It is understood that any dispute between AAQHC, An Administrator, and any of its members, including disputes as to medical malpractice, that is as to whether any medical services were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by constitutional right to have any dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. It is understood that this agreement to arbitrate shall apply and extend to any dispute between AAQHC, An Administrator, and its members, including any dispute for medical malpractice, any dispute relating to the delivery of service under the plan, and to any claims in tort, contract or otherwise, between AAQHC, An Administrator, and any individual(s) seeking services under the plan, whether referred to as a member, subscriber, dependent, enrollee or otherwise (whether a minor or an adult), or the heirs-at-law or personal representatives of any such individual(s), as the case may be. I HAVE READ ALL OF THE CONDITIONS AS STATED IN THIS MEMBERSHIP APPLICATION & GUIDELINES. I DECLARE THAT I AM FULLY AUTHORIZED TO SIGN THIS MEMBERSHIP APPLICATION & GUIDELINES ON BEHALF OF MYSELF AND MY ELIGIBLE DEPENDENTS (IF ANY).