First Name
Address
Last Name
City
State
Zip Code
Home Phone
Cell Phone
Email Address
Credit Card Type
Credit Card Number
Expiration Date
Security Code
(Found on the back 
of the card)
Online Application

Please choose the program(s) that you are interested in recieving. 
Once your application is recieved, your coverage will begin immediately. 
Ameriplan USA
Affordable Healthcare

AmeriPlan Dental $19.95
AmeriPlan Vision $19.95
AmeriPlan Prescription $19.95
AmeriPlan Basic Health Plan $29.95
AmeriPlan Total Health Plan $39.95
AmeriPlan Total Health Plus $59.95
AmeriPlan Chiropractic Program $19.95
AmeriPlan Prescription Advocacy $82