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Pro Medical RatesApplication

APPLICANT INFORMATION

Address

Effective Date

Group Name (If Applicable)

APPLICANTS INFORMATION AND PRIMARY CARE PHYSICIANS (PCP) SELECTION

Primary

* Down Payment is calculated based on your first and second month of coverage depending on the plan rate you (and your dependents) fall into and it may or may not include your application fee depending on your choice.

ProMedical Plan PHC, Inc.
400 Sawgrass Corporate Parkway Suite #200
Sunrise, FL 33325

If you decide to terminate your membership please email us at customerservice@promedicalplan.com