MyPhysicianPlan

Dates
Quote
Travelers
Payment

Start date*

End date*

Ages of Travelers*

All Plans include the following features

Routine Care with Dedicated PCP
Specialist, Hospital, Urgent care and Emergency Room Coverage
Acute Onset of a Pre-Existing Condition Benefit (up to 89 years of age)
Annual Wellness Exam including blood test with Dedicated PCP
United Healthcare (UHC) Global PPO network
Emergency Dental Expenses
Emergency Medical Evacuation/Repatriation Expense
Return of Mortal Remains or Cremation Expense

Note: The traveler must be healthy and stable at time of purchase with no known medical treatment needed.

Primary Address in US

Address *

Apartment, Unit, Suite, or Floor #

City*

State*

ZIP / Postal Code*

Email/Username*

Mobile Number*
-

* By providing Member phone number and email address, Member consents to receive text message and email correspondence from MPPI, including but not limited to products & services, appointments, claims, partners, maintenance, and support. Message and data rates may apply. Member may opt-out at any time by replying to any text message or email with the word “STOP” or by contacting MPPI support directly. By opting-in to receive text message and email correspondence, Member acknowledges that Member is the account holder or have the account holder's permission to enroll in this service.

Where are you travelling from?*

What is the reason of travel?*

Card Number*

Name (as on Card)*

Expiry Date (MM/YY)*

CVV*

Billing Address

Apartment, Unit, Suite, or Floor #

City*

State*

ZIP / Postal Code*

Country*

I Accept the Plan Terms ( View Exhibit A & B | View Policy Exhibit )

Health Attestation Form

I certify that (Member) visiting from (Home country) to USA (Destination Country) is not currently sick and not in any need of an emergency treatment or undergoing treatment or expecting to go under treatment in the immediate future.

Signature:

Date:

I have reviewed and attest to the Health Attestation Form above.

Selection Snapshot

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1-844-200-6999