Online Patient Sign-up

Please enter the information requested, and then click on the "Sign-up" button. The items marked with * are required.

Doctor/Clinic

Member Information

*Member First Name:

Member Middle Name:

*Member Last Name:

Member Suffix:

*Member Date of Birth:

*Member Address:

Member Address2:

*City:

*State:

*Zip:

Dependent Names:

(Spouse, Domestic Partner, Dependent Children up to age 26, Parents in the Household over age 60, and any other IRS Dependent)

NOTE: Email address is required. Your receipt and membership packet will be sent via email.

*Email:

(Email address required as fulfillment packet will be sent via email.)

Home Phone:

I hereby verify that a ChiroHealthUSA HIPAA form has been signed by the member and filed in their patient chart.

I hereby verify that member was presented HIPAA form but declined to sign.

I hereby verify that member has indicated their consent to communicate and the membership application is filed in the patient chart.

*Order Summary
$49.00/yr. CHIRO ONLY DISCOUNTS

$89.00/yr. CHUSA PLUS Chiro, dental, vision, prescription, lab, & diagnostic discounts (Not available in Alaska, California, Washington, Rhode Island or Vermont)

*Doctor NPI:

Enroll Date:
11/21/2024

REQUIRED: Click here to read and accept "Disclosure Statement".

Credit Card Information (HSA AND FSA ACCOUNTS FOR PAYMENT OF MEMBERSHIP FEES ARE NOT PERMISSIBLE.)

Use Member Name and Address

*Name as on Card:

*Card Billing Zip:

*Card Number:

*Card Expiration Date: MMYY

*Card ID (CVV2/CID) Number:

This discount medical plan is NOT insurance, a health insurance policy, a Medicare Prescription Drug Plan or a qualified health plan under the Affordable Care Act. This plan (The Plan) provides discounts only on chiropractic services offered by providers who have agreed to participate in The Plan. The range of discounts for medical or ancillary services offered under The Plan will vary depending on the type of provider and products or services. The Plan does not make and is prohibited from making members’ payments to providers for products or services received under The Plan. The member is required and obligated to pay for all discounted chiropractic services and equipment received under The Plan, but will receive a discount on certain identified chiropractic services from providers in The Plan. The Discount Medical Plan Organization is Alliance HealthCard of Florida, Inc., 5005 LBJ Freeway, Suite 1500, Dallas, TX 75244. ChiroHealthUSA members may call 1-888-719-9990 for more information or visit www.chirohealthusa.com for a list of providers. The Plan will make available before purchase and upon request, a list of program providers and the provider’s city, state and specialty, located in the member’s service area. Alliance HealthCard of Florida, Inc. does not guarantee the quality of the services or products offered by individual providers. The fees for The Plan are specified in the membership agreement. You have the right to cancel your membership at anytime. If you cancel your membership within 30 days of the effective date, you will receive a full refund of your membership fees other than money paid by you to a provider. To cancel your ChiroHealthUSA Plan you must, verbally or in writing, notify ChiroHealthUSA at 1-888-719-9990, 250 Katherine Drive, Flowood, MS 39232. Any complaints should be directed to Alliance HealthCard of Florida, Inc. at the address or phone number above. Upon receipt of the complaint, member will receive confirmation of receipt within 5 business days. After investigation of the complaint, Alliance HealthCard of Florida, Inc. will provide member with the results and a proposed resolution no later than 30 days after receipt of the complaint.
Note to DE, IL, LA, NE, NH, ND, OH, RI, SD, TX and WV consumers: If you remain dissatisfied after completing the complaint system, you may contact your state department of insurance. You may contact Alliance HealthCard of Florida, Inc. for department of insurance contact information.
Note to MA consumers: The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under M.G.L. c. 111M and 956 CMR 5.00

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