The Health Benefits Club  FREE PRESCRIPTION CARD REGISTRATION FORM MORE INFO: 1- 800.628.5061 Fill out the following necessary * required information below. Easy Signup Form Free Prescription Drug Card APPLICATION FOR FREE PRESCRIPTION CARD Primary Information *First Name: *Last Name: *Address: *City: *State: *Zip code: *Email: *Phone: EXAMPLE ( 303-455-6677 ) *Date of Birth: EXAMPLE ( 4/15/61 ) *Male: *Female:     DEPENDENTS All legal (claimed on taxes) dependents are included. Children are included up to age 19 and up to 25 if they are full-time students. Please call 1-800-628-5061 if you wish to add any dependents on your card. Employer Section   Fill out this part of form for employers needing pre-printed cards and brochures. Call for more info 1.800.628.5061 if needed. Company:  Attention:  ( Name  ) #Employees: ( Number of employees ) Brochures: (# of brochures needed ) Display Stands: 1 stand 25 Brochures Laminated Cards  ( a fee required for special laminated cards if needed  - price break for quantity ) Call 1.800.628.5061 Special Instructions: Form#HBC.011907-F

HEALTH BENEFITS CLUB
P.O. Box 741116 Arvada CO 80006

Representatives on hand:
Monday thru Thursday 
9am to 9pm
Fridays - 9am to 5pm EST

PHARMACY DISCOUNTS ARE NOT INSURANCE, AND ARE NOT INTENDED AS A SUBSTITUTE FOR INSURANCE

This discount card program contains a 30 day cancellation period.