Presbyterian Senior Connection Membership

Join Presbyterian Senior Connection!

Fill out the following form and print it out, then
send it with the credit card information or a check to:

Senior Services
Attn.: Linda McCollister
Healthplex 6301 Forest Hills NE
Albuquerque, NM 87109

Yes, I want to join the Presbyterian Senior Connection.

I am 60 years of age or older. I understand that by signing this enrollment form, I am authorizing Presbyterian to send me information regarding current and future benefit opportunities.

Name		Date of birth:
Spouse	(if joint application, must be 60 or older)	Date of birth:
Address
City, State, Zip
Phone
E-mail
Referred by:
Health Insurance Coverage
Primary Care Physician
Emergency Contact
Relationship
Emergency Contact's Phone Number
Please charge my Visa MasterCard
Account No.:
Expiration Date:
Self only Self and spouse		(One-time fee of $10) (One-time fee of $15)

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