ADMINISTRATIVE HEALTH FUND

AUTHORIZATION AND PAYMENT PLAN

PLEASE COMPLETE THE HIGHLIGHTED FIELDS.  

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I, ,wish to take part in the Wellness Plan managed by AHF Administrative Health Fund) and endorsed by the San Diego Police Officers Association, Inc
Enclosed is my check in the amount of $290.00 for one year membership.
                                                        OR
I authorize ADMINISTRATIVE HEALTH FUND to debit:
1. My checking account card #: MC Visa
2.MyVISA orMASTERCARD #:
Card Expiration Date:
At the rate of $290. per year effective immediately OR $25.00 per month on the fifteenth of every month for a minimum of twelve months (total $300.00 per year).
I authorize my employer to institute a payroll deduction in the amount of $25. per month, beginning with the first payroll after the date on this form, for a minimum of 12 months. The San Diego Police Officers Association, Inc. will pay this administration fee to Administrative Health Fund on a monthly basis.

Employer:
Employee:
                                         Print full name (first, middle and last)
Street Address:
City, State and Zip Code:
Home phone:Work Phone:
Employee ID Number:Birthday:

The above authorization will entitle the member, while actively employed by the San Diego Police Department, their spouse/domestic partner (with proof of cohabitation exceeding one year), minor children (under age 19), or stepchildren (under age 19 and living in the members home); to referrals to specific alternative health care offices. This authorization shall remain in effect for a period of no less than ONE YEAR, unless just cause is presented to Administrative Health Fund by the member. This authorization will be discontinued only upon receipt of a written request by the member, with thirty days to act upon said request.

It is the duty of the member to notify Administrative Health Fund within ten days if any of the above information changes.

I understand that Administrative Health Fund has no responsibility other than providing me with the names and locations of participating providers. Administrative Health Fund, their personnel and representatives, as well as the San Diego Police Officers Association, Inc. and their agents, shall be held harmless from any actionable event, incident or accident which may occur. My signature below indicates, under penalty of perjury, that the above information is true and correct; and that I have read, understand and accept all the terms of this agreement.

Member Signature:Date:

ADMINISTRATIVE HEALTH FUND
P. O. Box 212408
Chula Vista, CA 91921
Phone: (800) 792-3004 or (360) 678-3485
Fax: (619) 934-2061
Email: ad.health@yahoo.com Website: www.adhealthplan.com