;
Member registration for Plan or Free Rx Card
Step 1: Member Details
Step 2: Select a Plan
Step 3: Enroll
MyPhysicianPlan
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MyPhysicianPlan
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Step 1: Enter Member Details
If you already have an account please
Login here
Referring Member
Referring Member ID
Member Details
First Name
*
Last Name
*
Date of Birth
*
Age
*
Gender
Male
Female
Salutation
*
Email
*
Mobile Number
*
-
ZIP / Postal Code
*
-
Country
*
State
*
City
*
Login Credentials
UserName
*
Confirm Username
*
Password
*
Confirm Password
*
Enable 2-factor authentication
Everytime
Only when system change
Continue to Plan Enrollment
Get Free Rx Card
I Accept the
for Member
Check Terms and Condition
Step 2: Select Plan / Provider
Search by Location or Provider
State
*
City
ZIP / Postal Code
*
Facility Name
Provider Name
Plan Name
Change search
Back
Search
Select a Provider
Select
Organization Name
Provider Name
ProviderAddress
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Select a Plan
Select
Plan Name
Provider Name
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Select Plan Start Date / Payment Schedule
Plan start date
*
Payment Schedule
Total Amount
No. of Installments
Installment Amount
Installment Fee
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Next
Step 3: Enroll
Selected Plan
Plan Name
Plan Type
Plan Duration
Visit Fee
In-person visit: $35, Televisit: $25
Plan Amount
$
Enrollment Fee
$
Plan Start date
Plan End Date
Payment Schedule
Installment Amount
$
Installment Fee
$
Referral Discount
Terms (No. of payments)
Plan Decription
AccountID
Pay Now
Please enter Card Details :
Amount
*
$
Card Number
*
Name On Card
*
Expiry Date (MM/YY)
*
CVV
*
I Accept the
Terms & Conditions
for Member and the
Plan Terms
Check Terms and Condition
Back
Submit
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Return to Login
Next
Submit
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MyPhysicianPlan, Inc.
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