PlusClub

www.montefiore.org

Update your information and enter the raffle to win a flat screen TV.

INSTRUCTIONS: Please enter your Plus Club Member Number along with any neccessary changes below. Once complete, press the submit button.

	Correct My Information! My membership information has changed or is not correct. Please review your information on your mailer and make the necessary changes below.

	Say Goodbye! I no longer wish to be a member of the Plus Club. Please check the information listed below to confirm we are removing the correct person from our files.

	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.
	Email Address (optional)

	Plus Club Member Number		MPC-
	Prefix		Mr. Ms. Mrs.
	First Name/Last Name
	Address
	City
	State
	Zip
	Telephone
	Birthdate (mm/dd/yyyy)		/ /
	Race or Ethnicity (optional)

	Insurance Company (check all that apply)
	Managed Care	Medicaid	Medicare	HealthFirst
	HIP	AETNA	Oxford	Empire Blue Cross Blue Shield
	Other None
	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

	Only one entry per person. Current Montefiore associates are not eligible for this drawing.