Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Cell: 248-252-1719. Helped this member renew over the phone, gave ranges for DLN OS Hildebrand, fee sched 112. Range for extractions, braces. I explained procedure codes, they are going to try and get those and will call back to verify. 6/7/2021 MT |
| Membership Type | Individual Plan ($99.95) |
| Are you renewing your plan? | Yes |
| Please enter your current membership ID# here. You can find this in your renewal email or on your current membership card. | 1755526200 |
| Your Name | Michael Bilas |
| Email hidden; Javascript is required. | |
| Phone | (248) 252-1719 |
| Date of Birth | 12/02/1942 |
| Referred by or Referral Code | Fax 8/27/18, ExMail 6/8/22 |
| Enter Office Code | A22062 |
| Address | 17380 Canvasback Dr Macomb, MI 48044 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX3168 |
| Total | $99.95 |
| Go Green | Paperless Option | not |
| Terms |  I have read the Terms and Conditions and wish to purchase the Discount Medical Plan. |
| Plan Information | |
| Newest Membership: Programmatically pick Plan Start Date Based on either new plan or their ID number here | 11/12/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/12/2027 |
| Membership ID Number | 1791313521 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 7 |
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