Become a Subscriber

Please complete the information below.

Name   ____________________________________________________

Address  ________________________________________________________

City  ______________________________________  State _____   ZIP ____________

Phone  _____________________________________

Email Address  ___________________________________________________

Subscription Levels:

 

¨  Single    $60.00

     Anyone 18 years of older, living on their own.

¨  Family    $85.00

     Spouses and their dependent children under age 18.

¨  Senior Single    $55.00

     Anyone 62 years or older, living on their own.

¨  Senior Couple    $65.00

      Includes couple with one spouse being 62 years or older

¨  Extended Family   $125.00

      Spouses and their related adult household

                 (ie: children over 18 years of age and/or elderly family members)

Please list all family members residing at this address to be covered by this Subscription                        Date of Birth

_______________________________________________________________________                          ______________

_______________________________________________________________________                          ______________

_______________________________________________________________________                          ______________

_______________________________________________________________________                          ______________

_______________________________________________________________________                          ______________

 

Authorization

I understand that I am financially responsible for the services provided to me or my family members by this health service provider supplier regardless of my insurance coverage.  I request that payment of authorized Medicare or other insurance benefits be made on my behalf to the health service provider or supplier or its billing agent for any services provided to me by the health care provider or supplier.  I authorize and direct any holder of medical information or documentation about me to release to the Center for Medicare and Medicaid Services and its carriers and agents, as well as to the health provider or supplier and their billing agents, any information or documentation needed to determine these benefits payable for any services provided to me by the health service provider, both now or in the future.  A copy of this form is as valid as the original.  I also agree to immediately remit to health service provider any payments that I receive directly from any source for the services provided to me, now or in the future.

Signature_____________________________________________________                Date _______________________

 

Complete Form and Mail with check/money order to:

              UPVAA

2199 E. Buck Road

                       Pennsburg, PA 18073