Purchase a Plan for Your Family

Member Information

I understand that signing up for an individual and/or family plan from Vision Care Direct requires me to use an in-network provider. There is no out of network availability.

Add Dependent

Affirmation of Supplied Information

I affirm that all the information and statements provided by me in this Questionnaire to be true, complete and factual. I understand that any false or incomplete information regarding this form will affect my membership.

Please note, an electronic signature is legally valid and binding in accordance with the United States Electronic Signatures in Global and National Commerce Act (ESIGN Act). Also, in accordance with the ESIGN Act you are granted the right to choose to submit a paper copy of this form instead. If you do not want to sign electronically, you may download and fill out the PDF version of this form.

I hereby acknowledge that I have received, read and understand the Plan I have selected and the options that are available.

Payment Information

Expiration Date  /  24

Name On Card

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Recurring Amount:
Initial Payment will be withdrawn today and will reccur on this day each month going forward.

Draft Authorization/Member Agreement: Unless I have selected Annual Payment by check or credit card, I hereby authorize Vision Care Direct to charge my account the application membership fee, to be credited to my account with Vision Care Direct. This authorization is to remain in full force and effect until I notify Vision Care Direct in writing of its termination. (My bank is authorized to make corrections if necessary). I have read and understand the terms of this authorization. I agree to maintain membership for a period of one year. Less than one year membership will result in being billed by the providers at their usual and customary rate, minus membership fees paid. All membership fees are non refundable. By submiting this application I agree to these terms.