H&A Media Group
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Questions?

Call 402.965.4000

Enroll Now


Fill out and electronically submit the enrollment form below or download the printable version and mail to: HealthGap - Administration, 3830 N 167th Ct, Omaha NE 68116. DO NOT SEND MONEY AT THIS TIME. You will be billed for your first month's payment.
Choose Your Membership:
Individual Membership*
$50 monthly fee + $10 per visit,
due at the time of service
*This is not an insurance plan.
Two-Person Membership*
$65 monthly fee + $10 per visit, per person,
due at the time of service
*This is not an insurance plan.
3+ Family^ Membership*
$75 monthly fee + $10 per visit, per person,
due at the time of service
*This is not an insurance plan.
^For family up to 5 persons. Additional family members may be added for $10 each to monthly fee.
 
Your Information:
Full Name:* 
Date of Birth:* 
Phone:* 
Email:* 
Address:* 
Address 2: 
City:* 
State:* 
Zip:* 
*Required fields
 
Other Family Members' Information:
1) Full Name: 
Relationship: 
Date of Birth: 
2) Full Name: 
Relationship: 
Date of Birth: 
3) Full Name 
Relationship: 
Date of Birth: 
4) Full Name: 
Relationship: 
Date of Birth: 
5) Full Name: 
Relationship: 
Date of Birth: 
6) Full Name: 
Relationship: 
Date of Birth: 
NOTE: Once your enrollment is processed, you will receive a statement in the mail requesting 1st month's payment.