<%@ Language=VBScript %> <% 'if (Request.ServerVariables("http")) = "off" then Response.Redirect("http://www.advantagecareplus.com/enroll.asp") Dim Errors Dim TempStr Dim ID Dim FirstName Dim LastName Dim Phone Dim Email Dim EmailInvalid Dim Address Dim City Dim State Dim Zip Dim CreditCardType Dim CreditCardNumber Dim CreditCardNumberInvalid Dim CreditCardExpiration Dim CreditCardExpirationInvalid function ValidEmailAddress(EmailAddress) Dim Str 'required to be in the minimum form of x@x.xx ValidEmailAddress = True if Trim(EmailAddress) = "" then ValidEmailAddress = False elseif InStr(EmailAddress, "@") <= 1 then ValidEmailAddress = False else Str = Mid(EmailAddress, InStr(EmailAddress, "@") + 1, Len(EmailAddress)) if Instr(Str, ".") <= 1 then ValidEmailAddress = False else Str = Mid(Str, InStr(Str, ".") + 1, Len(Str)) if Len(Str) < 2 then ValidEmailAddress = False end if end if end if end function function trimtodigits(tstring) Dim s Dim ts Dim x Dim ch 'removes all chars except of 0-9 s = "" ts = tstring for x = 1 to len(ts) ch = mid(ts, x, 1) if asc(ch) >= 48 and asc(ch) <= 57 then s = s & ch end if next trimtodigits = s end function function CheckState(St) Dim SelectedStr if Request.Form("state") = St then SelectedStr = " selected" else SelectedStr = "" end if CheckState = "" & St & "" end function function checkcc(ccnumber, cctype) 'Test Numbers 'Visa 4111-1111-1111-1111 'MC 5111-1111-1111-1118 'AE 3411-1111-1111-111 'Disc 6011-1111-1111-1117 'checks credit card number for checksum,length and type 'ccnumber= credit card number (all useless characters are 'being removed before check) ' 'cctype: ' "V" VISA ' "M" Mastercard/Eurocard ' "A" American Express ' "C" Diners Club / Carte Blanche ' "D" Discover ' "E" enRoute ' "J" JCB 'returns: checkcc=0 (Bit0) : card valid ' checkcc=1 (Bit1) : wrong type ' checkcc=2 (Bit2) : wrong length ' checkcc=4 (Bit3) : wrong checksum (MOD10-Test) ' checkcc=8 (Bit4) : cardtype unknown ' Dim CType Dim CCLength Dim CCPrefix Dim Prefixes Dim Prefix Dim Lengths Dim Length Dim Number Dim PrefixValid Dim LengthValid Dim Result Dim QSum Dim ch Dim Sum Dim x ctype = ucase(cctype) select case ctype case "V" cclength = "13;16" ccprefix = "4" case "M" cclength = "16" ccprefix = "51;52;53;54;55" case "A" cclength = "15" ccprefix = "34;37" case "C" cclength = "14" ccprefix = "300;301;302;303;304;305;36;38" case "D" cclength = "16" ccprefix = "6011" case "E" cclength = "15" ccprefix = "2014;2149" case "J" cclength = "15;16" ccprefix = "3;2131;1800" case else cclength = "" ccprefix = "" end select prefixes = split(ccprefix,";",-1) lengths = split(cclength,";",-1) number = trimtodigits(ccnumber) prefixvalid = false lengthvalid = false for each prefix in prefixes if instr(number, prefix)=1 then prefixvalid = true end if next for each length in lengths if cstr(len(number))=length then lengthvalid = true end if next result=0 if not prefixvalid then result = result + 1 end if if not lengthvalid then result = result + 2 end if qsum = 0 for x = 1 to len(number) ch = mid(number,len(number)-x+1,1) 'response.write ch if x mod 2=0 then sum = 2 * cint(ch) qsum = qsum + (sum mod 10) if sum > 9 then qsum = qsum + 1 end if else qsum = qsum + cint(ch) end if next 'response.write qsum if qsum mod 10 <> 0 then result = result + 4 end if if cclength = "" then result = result + 8 end if checkcc = result end function function ValidateInput On Error Resume Next if Trim(Request.Form("firstname"))="" then FirstName = true end if if Trim(Request.Form("lastname"))="" then LastName = true end if if Trim(Request.Form("address"))="" then Address = true end if if Trim(Request.Form("city"))="" then City = true end if if Request.Form("state")="" then State = true end if if Trim(Request.Form("zip"))="" then Zip = true end if if Trim(Request.Form("phone"))="" then Phone = true end if if Trim(Request.Form("email"))="" then Email = true elseif not ValidEmailAddress(Request.Form("email")) then EmailInvalid = true end if if Request.Form("creditcardtype")="" then CreditCardType = true end if if Request.Form("creditcardnumber")="" then CreditCardNumber = true elseif Request.Form("creditcardtype") = "Visa" and CheckCC(Request.Form("creditcardnumber"), "V") <> 0 then CreditCardNumberInvalid = true elseif Request.Form("creditcardtype") = "Mastercard" and CheckCC(Request.Form("creditcardnumber"), "M") <> 0 then CreditCardNumberInvalid = true elseif Request.Form("creditcardtype") = "American Express" and CheckCC(Request.Form("creditcardnumber"), "A") <> 0 then CreditCardNumberInvalid = true elseif Request.Form("creditcardtype") = "Discover" and CheckCC(Request.Form("creditcardnumber"), "D") <> 0 then CreditCardNumberInvalid = true elseif Request.Form("creditcardtype")="" then CreditCardNumberInvalid = true end if if Request.Form("creditcardexpirationmonth") = "Mo" or Request.Form("creditcardexpirationyear") = "Year" then CreditCardExpiration = true else if CInt(Request.Form("creditcardexpirationyear")) = CInt(DatePart("yyyy", Date)) then if CInt(Request.Form("creditcardexpirationmonth")) < DatePart("m", Date) then CreditCardExpirationInvalid = true end if end if end if if FirstName or LastName or Phone or Email or EmailInvalid or Address or City or State or Zip or CreditCardType or CreditCardNumber or CreditCardNumberInvalid or CreditCardExpiration or CreditCardExpirationInvalid then ValidateInput = false else ValidateInput = true end if end function if UCase(Request.ServerVariables("Request_Method")) = "POST" then if ValidateInput then '***************************** ' INSERT RECORD IN DB '***************************** Set conAC = Server.CreateObject("ADODB.Connection") conAC.Open ConnectionString sql = "insert into enrollments (firstname, lastname, address, city, state, zip, phone, email, creditcardtype, creditcardnumber, creditcardexpiration, enrollmentdate) values('" & Replace(Request.Form("firstname"), "'", "''") & "','" & Replace(Request.Form("lastname"), "'", "''") & "','" & Replace(Request.Form("address"), "'", "''") & "','" & Replace(Request.Form("city"), "'", "''") & "','" & Request.Form("state") & "','" & Request.Form("zip") & "','" & Replace(Request.Form("phone"), "'", "''") & "','" & Replace(Request.Form("email"), "'", "''") & "','" & Request.Form("creditcardtype") & "','" & Encrypt(Replace(Replace(Request.Form("creditcardnumber"), "-", ""), " ", ""), CryptoKey) & "','" & Request.Form("creditcardexpirationmonth") & "/" & Request.Form("creditcardexpirationyear") & "','" & Now & "')" response.write sql conAC.Execute(sql) sql = "select @@Identity" set rst = conAC.Execute(sql) ID = rst(0) '***************************** ' SEND OFF EMAILS '***************************** Dim Subject Dim ReplyToAddress Dim ReplyToName Dim SendToAddress Dim SendToName Dim SendToCCName Dim SendToCCAddress Dim MsgText Dim Result Set conAC = Server.CreateObject("ADODB.Connection") conAC.Open ConnectionString sql = "select * from enrollments where id = " & ID set rst = conAC.Execute(sql) Subject = "AdvantageCare Enrollment" ReplyToAddress = rst("Email") ReplyToName = rst("FirstName") & " " & rst("LastName") SendToAddress = "sales@charteredmarketing.com" SendToName = "Sales" SendToCCAddress = "" SendToCCName = "" SendToCCAddress = "nshreeves@charteredmarketing.com;calcauter@charteredmarketing.com;NewBusiness@charteredmarketing.com" SendToCCName = "Sales Support;Sales Support;Sales Support" MsgText = "A new Advantage Care enrollment has been received. Go to http://secure.netsolhost.com/www.advantagecareplus.com/secure/maintlogin.asp to view." Result = SendMail(Subject, ReplyToAddress, ReplyToName, SendToAddress, SendToName, SendToCCAddress, SendToCCName, MsgText, "", 1) if Result <> "" then Response.Write "Mail failure occured. Reason: " & Result & "
" end if Subject = "AdvantageCare Plus Enrollment" ReplyToAddress = "ACP@charteredmarketing.com" ReplyToName = "Alex Peterson" SendToAddress = rst("Email") SendToName = rst("FirstName") & " " & rst("LastName") SendToCCAddress = "" SendToCCName = "" MsgText = "We always appreciate hearing from you and look forward to serving you in any " _ & vbCrLf & "way we can. For assistance with Advantage Care Plus or if you have any" _ & vbCrLf & "questions, please call our Customer Service Department at 1-800-332-2853 " _ & vbCrLf & "Monday through Friday from 7:00 a.m. to 8:00 p.m. (Central Time). We " _ & vbCrLf & "appreciate the opportunity to serve you." Result = SendMail(Subject, ReplyToAddress, ReplyToName, SendToAddress, SendToName,SendToCCAddress, SendToCCName, MsgText, "", 1) if Result <> "" then Response.Write "Mail failure occured. Reason: " & Result & "
" end if rst.Close conAC.Close Response.Redirect "enrollcomplete.asp" else Errors = true end if end if %> Advantage Care Plus | Enrollment <% if (Errors) then %><% end if %>

Chiropractic
Dental
Vision
Hearing
Prescriptions

24 hour access to
Medical Records

Travel Protection Assistance

The Medical Records and Travel Protection benefit are not available to residents of CT & FL

Members can call 1-800-332-2853 for Benefit Information

As a member of AdvantageCare Plus you will receive healthcare discounts of 10% to 60% for you and your family.

AdvantageCare Plus is not an insurance plan so there are no forms to fill out. This program is a discount medical plan offering members savings on important health care services. Our skilled professionals are located across the country and will give you great care at discounted prices.

How it Works

Present the Card
You’ll receive a discount card in your membership kit. Present it to one of the 80,000 participating providers across the country.

Use it to be Healthy
Pharmacies, Vision Centers, Dentists and many more locations have special discounts for you as a member.

Immediate Savings
The discounts are given at the time of service so there are no forms to fill out or having to wait for reimbursement.

 

Healthcare Savings

Your AdvantageCare Plus membership provides unlimited savings on:

ServicesAverage Savings*
Chiropractic 20%-40%
Dental Care 10%-50%
Vision Care 10%-60%
Hearing 10%-20%
Prescription Drugs (Retail) Up to 30%
Prescription Drugs (Mail Order) Up to 50%

Hours of Operation
Mon - Fri    8:00am - 5:00pm cst
Sat and Sun    CLOSED

*Your actual savings will vary by region and service

Membership card that can be used
at over 80,000 locations

Member's Guide detailing all of
the savings opportunities

Emergency Travel Benefits

Electronic Medical Records

Disclosure

This plan is NOT insurance. This is not a qualified health plan under the Affordable Care Act. This is not a Medicare prescription drug plan. The plan provides discounts at certain health care providers for medical services. The plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount medical plan organization. The range of discounts will vary depending on the provider type and services provided. This plan is administered by Coverdell & Company, Inc., a discount medical plan organization, at 8420 W. Bryn Mawr, Suite 700, Chicago, IL 60631, 1-800-308-0374. To view a listing of participating providers visit www.advantagecareplus.com. You have the right to cancel this plan within 30 days of the effective date for a full refund of fees paid.