doctor, write prescriptions, handsome doctor

Enroll the plan in 3 simple steps

  • Print the following form

  • Fill out the entire application

  • Send the application with your payment for 2 months to the following address: 8333 W. Mc. Nab Rd, Tamarac, FL 33321

  • For question how to complete the application please call 1-888-776-7258

Download the Form:

Instructions for filling out your enrollment form Member Agreement Benefits & Services

Instructions for filling out your Prosalud Plan membership form

 

“MEMBERSHIP”

Personal information: This table must clearly record the information of who is joining the Plan (New member of CSMC Prosalud Plan).

Please indicate the name of the healthcare professional you wish to be your primary physician. You can change it once a month, whenever you want, by dialing (954)718-3393 before the 15th day (see medical directory)

If the member is under 18 years of age: If the member (New member of CSMC Prosalud Plan) is not yet 18 years of age, this table must record the information of one of their parents or whoever is under their parental authority “Guardian” . A proof (Certification) of parental authority is required and this is the person who must sign the application (Page 3/3), also indicating her full name.

Plan Selection: Please note that CSMC Prosalu Plan has two plans “A” Medical Centers “Colony Springs Medical Center”, and “B” Affiliated Medical Centers, Physicians enrolled in Colony Sprins Medical Center will carry the identification “CSMC” to the right side of their name (see directory).

Plans “A” and “B” CSMC Prosalud Plan include medical, dental and vision plans, but if you want additional ones, please indicate them in lines 2, 3 and 4 of this table.

If you chose one of the CSMC doctors as your primary doctor, make the settlement of your first payment in column “Plan A” or, if you chose an affiliated doctor, make the settlement of your first payment in column “Plan B” . In the two alternatives, the initial payment is three (3) monthly payments (anticipated) plus the administration cost ($ 30.00) that is $ 120.00. If you wish to pay semi-annually or annually, multiply $ 30.00 (value of the monthly payment) x 6 or x 12 as you wish, add $ 30.00 of administration cost and enter the corresponding total.

Payment method: Indicate in this box if you want to make your payments by check by mail, with automatic charge to your bank account or with automatic charge to your credit card. The charges will be on the 15th or the 30th depending on their effective date in CSMC Prosalud Plan.

Payment Periods: Indicate in this box how you want to make your payments or charges: monthly, quarterly, semi-annually, or annually.

Credit card information: If this was the payment method you chose, this table must be filled out (filled out) and signed by the holder of the credit card to which the successive charges will be made.

Information for direct bank withdrawal: If this was the payment method you chose, this table must be filled out (filled out) and signed by the owner of the bank account to which the successive charges will be made. A voided check from the used account must be attached to this membership form.

Note: Please initial (Abbreviated Signature) in the lower right corner of this page.

“AGREEMENT WITH MEMBER”

Please read the content of this page carefully and if you agree with its content, put your initials (abbreviated signature) in the lower right corner of the page.

“BENEFITS AND SERVICES”

Please read the content of this page carefully and if you agree with everything, write at the bottom of the page your full name (legible) and sign, in your own name, if you are the applicant (of legal age), or on behalf of the applicant if he is a minor.

Please send this duly completed application form by mail to CSMC Prosalud Plan, 8333W Mc Nab Rd Suite 129 Tamarac, Florida, 33321, along with a check or “Money order” for the first payment and the required attachments (if any) . By return mail you will receive an accepted copy, a welcome letter, your card, an operation manual of the Plan and a brochure with all the services of CSMC Prosalud Plan.

Thank you for becoming part of the great membership of CSMC Prosalud Plan. We want to always serve you more and better.

“Your first consultation is free at the CSMC centers”, and in addition, you will get a 20% discount on your first order for our diagnostic center.