Member Sign-Up

Membership Type *

Select the membership type

Need more info on our memberships? Check out our guide. 👇

Pick the IUA *

$1,250

$2,500

$5,000

Coremed Primary(No IUA)

Do you want to Opt in for Preventive Sharing?

Need more information about Preventive Sharing? Take a look at our guide. 👇

Are you a smoker and want to Opt in for Tobacco Surcharge?

Not sure about your IUA? Take a look at our guide. 👇

Primary Member Info

First Name *

Last Name *

Date of Birth *

(MM/DD/YYYY)

Sex *

Male

Female

Do you know what doctor you want to work with?

Primary Contact Info

Primary Phone *

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (XXX) XXX-XXXX for assistance. You can reply STOP to unsubscribe at any time.

Email *

Address *

No PO BOX allowed

City *

State *

Zip Code *

Add Spouse? *

Yes

Spouse Info

First Name

Last Name

Phone

Date Of Birth

(MM/DD/YYYY)

Spouse Sex

Male

Female

Add Children?

Yes

Add Children??

Yes

Child 1

First Name

Last Name

Date of Birth

(MM/DD/YYYY)

Sex of Child 1

Male

Female

Child 2

First Name

Last Name

Date of Birth

(MM/DD/YYYY)

Sex of Child 2

Male

Female

More Kids?

Yes

Child 3

First Name

Last Name

Date of Birth

(MM/DD/YYYY)

Sex of Child 3

Male

Female

Child 4

First Name

Last Name

Date of Birth

(MM/DD/YYYY)

Sex of Child 4

Male

Female

Do you have more kids?

Yes

Child 5

First Name

Last Name

Date of Birth

(MM/DD/YYYY)

Sex of Child 5

Male

Female

Child 6

First Name

Last Name

Date of Birth

(MM/DD/YYYY)

Sex of Child 6

Male

Female

Product Cost Estimate

Check Out

Please note: The first payment will run only on 1st of the next month.

Payment Method *

Credit Card Type

Credit Card Number

Credit Card Expiry Month

Credit Card Expiry Year

CVV2

Account Type

Routing Number

Account Number

Bank Name

Account Holder Fist Name

Account Holder Last Name

Payment Address

Payment Zip Code

Payment Terms *

I confirm that the payment information provided is accurate, valid, and active, and I authorize this payment method charge the transaaction fee(ACH-1%, Credit Card-3.5%). If the payment is returned, rejected, or otherwise fails, I agree to pay any additional fees or costs incurred and provide an updated payment method to complete the payment.

Terms and conditions *

I am enrolling in the CoreMed Memberships quoted to me above.

I will be responsible to submit payment for my CoreMed Memberships on the 1st of every month.

My membership will be effective on the 1st day of next month.

To cancel my membership, I will give CoreMed 30-days-notice, either verbally or written, to allow adequate timeline notifications to necessary CoreMed Service Providers.

I am not buying health insurance through CoreMed. This is an alternative way for me to access the health system.

Done!!!

Click Submit Button to complete the enrollment.