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The Montefiore PLUS Club is a free membership program for adults age 55 and older offering special benefits, services and information to help you stay healthy and active, and makes it easy to receive healthcare services at Montefiore's hospitals and outpatient ofices.

* You must be 55 years of age or older to qualify. Montefiore associates are not eligible for membership.

INSTRUCTIONS: Please complete all fields below and press the submit button at the bottom of the page. Your Montefiore PLUS Club card will arrive in approximately 6-8 weeks.
   
Join the Club! I would like to apply for membership in the Montefiore PLUS Club.
   
Yes! Sign me up to be a Plus Club XPress member! I want to be the first to receive
exclusive promotions, invitations to special events and health news by email.
 
   
Mr. Ms. Mrs.
      
  First Name/Last Name      
       
       
       
       
       
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  Race or Ethnicity (optional)      
   
  Insurance Company (check all that apply)
  Medicaid Medicare HealthFirst  
  HIP AETNA Oxford Empire Blue Cross Blue Shield
 
  Please note: You will NOT be billed for any services we provide.
   
  Please help us serve you better by answering the following questions:
  How often do you use the Internet to find information? Never Sometimes Often
  Do you have a Montefiore Primary Care doctor? Yes No    
  Have you ever received care from a Montefiore specialist? Yes No    
  Have you ever used a Montefiore Emergency Department? Yes No    
  Do you feel that you have gained beneficial health information as result of your PlusClub membership? Yes No