Rx101 Program Enrollment 2301 Payne Avenue Cleveland, OH 44114 Phone: 216-472-8000 Fax: 216-472-8002
Member Information
Use the 'Tab' key to move to the next form field.
First Name:
Middle Initial:
Last Name:
Street Address:
Mailing Address:(if different than above)
City:
State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
Zip Code:
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Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Year: 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Gender: Select One Male Female
Social Security #: - -
Phone: 1 - - -
Email Address:
Spouse and Dependent Information is only needed if you are enrolling in the Family Plan.
Spouse Information
First Name: Last Name: Middle Initial: Gender: Select One Male Female
Date of Birth
Month: January February March April May June July August September October November December Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Dependent Information
I have read and agree to the Terms and Conditions of CreditUnionRx.
Enrollee Signature: Type your name here, it will act as an electronic signature.
Date Signed:
Please Select Plan and Payment Method: There is a $10.00 one time enrollment fee that will be added to your payment. Select One Single Plan - $20.95 Paid Monthly [paid by credit card or paypal] Single Plan - $239.40 Paid Yearly [paid by credit card or paypal] Family Plan - $30.95 Paid Monthly [paid by credit card or paypal] Family Plan - $359.40 Paid Yearly [paid by credit card or paypal] Single Plan - $19.95 Paid Monthly. [paid by echeck] Single Plan - $239.40 Paid Yearly [paid by echeck] Family Plan - $29.95 Paid Monthly [paid by echeck] Family Plan - $359.40 Paid Yearly. [paid by echeck]
Upon making your selection , please click on "Click here to Continue" - you will taken to our secure server to complete setup of your account - please ALLOW 60 seconds to connect to this server.
Thank you in advance for your business.
