RMC Wellness Plan Application Form I agree to abide by the Wellness Plan rules and policies * Yes   Monthly Dues $58 Member aged 18-49 yrs with no chronic conditions $86 Member aged 50+ with no chronic conditions $115 Any age with chronic conditions; COPD, diabetes, heart disease, etc $29 Minors aged 6 months thru 17 $19 Digital Imaging Option     Required fields are designated by *   Primary Member Full Name * Address * City & Zip Code * Primary Phone # * Primary Email Address * Primary Date of Birth dd/mm/yy * Primary Serious Medical Conditions? * Yes No If yes please list conditions/medications Primary- Add Digital Imaging? Covers MRI's,CAT Scans, Ultrasounds and Vein studies- No Copay Only $19 per month * Yes No Add Family Dental Plan for only $12.95 month * please note that the plan is administered by Careington Dental and has no affiliation with RMCDC. You will be sent a link to an online application in a seperate email. Yes No Family Member 1 Name Member 1 Date of Birth dd/mm/yy Member 1 Serious Medical Conditions? Yes No If yes please list conditions/medications Member 1 Add Digital Imaging? Yes No Family Member 2 Name Member 2 Date of Birth dd/mm/yy Member 2 Serious Medical Conditions? Yes No If yes please list conditions/medications Member 2 Add Digital Imaging? Yes No Family Member 3 Name Member 3 Date of Birth dd/mm/yy Member 3 Serious Medical Conditions? Yes No If yes please list conditions/medications Member 3 Add Digital Imaging? Yes No Family Member 4 Name Member 4 Date of Birth dd/mm/yy Member 4 Serious Medical Conditions? Yes No If yes please list conditions/medications Member 4 Add Digital Imaging? Yes No Please enter information for Credit or Debit Card Plan dues are drafted from your account on the 24th of each month Credit or Debit Card Type Visa Mastercard Discover Name on Card Card Address (where statements are sent) Card Account No. Card Expiration Date   Comments or Questions? How did you hear about The Wellness Plan?       Internal