Consumer Enrollment Application

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Terms of Agreement

1. Benefits begin when fees are paid.

2. Family membership is defined as your spouse or children under age 21 living at home.

3. Your membership serves as an agreement in which the PCD program provides you access to competent participating chiropractors who have agreed to offer discounted services and supplies to PCD members.  This is not an indemnity insurance plan or contract.  PCD does not reimburse your provider for service and fees paid cannot be used as payment for deductibles or co-payments.

4. This agreement is void in combination with any third party payer, personal injury claims, Worker's Compensation claims, or outside agreements between you and your doctor.  If you choose to suspend your membership due to a change in status (third party payer or any of the above claims, etc...) re-activation will be allowed should you again qualify.  Time unused will not be pro-rated.

5. Should your PCD provider lose membership privileges, you may be entitled to a refund of your annual fee as determined by the Board of Directors; otherwise, all fees paid to PCD are strictly non-refundable, except as provided by law.

6. As a PCD member, you are entitled to use any participating PCD Provider.  For a provider in your area, call the PCD offices at 1-800-239-3552.  Our regular office hours are Monday - Friday, 8:00 am - 5:00 pm CST.

7. Payment of services is due to your doctor at the time services are rendered.  Your chiropractor has the option of billing for visits and is entitled to assess a handling fee of not more than 15 percent.

8. You must present your I.D. card, or otherwise verify membership, in order to be eligible for PCD provider discounts.

9. Failure to abide by the terms of this agreemtn may result in loss of membership.

Submitting the application form below verifies 
you read and agree to the terms as enumerated above.