Member Acknowledgments. The undersigned Member understands, acknowledges and agrees with the Company as follows:
Member Acknowledgments. You acknowledge that: From time to time, due to emergency situations such as medical emergencies and natural disasters, the Practice may not have a Physician or Nurse Practitioner available. Services offered under this Agreement are beyond the coverage of any insurance plan you have, and the Practice will not seek reimbursement from your plan for services covered under this Agreement. The Practice may xxxx your insurance plan for services provided to you that are not covered by this Agreement, and you and/or your plan will be financially responsible for such services. The annual fee does not affect the co-payments, co-insurance, or deductibles you are required to pay under the terms of your insurance coverage. You agree that you will not seek reimbursement of the annual fee from your insurance plan, unless such fee is covered by your plan. The Practice makes no representations whatsoever that the fees paid under this Agreement are or are not covered by your own health insurance or by other third party plans that might provide you coverage. Term and Termination. You will receive the services for one (1) year beginning first day of the month you enroll. This Agreement will automatically renew from year to year unless you notify Practice in writing that you do not wish to renew. You may terminate this Agreement at any time by giving written notice. The Practice may terminate this Agreement if you fail to pay the fee; you have performed an act that constitutes fraud; you have repeatedly failed to comply with the recommended treatment plan; you are abusive and present an emotional or physical danger to the staff or other patients of the Practice; or the Practice discontinues operation as a direct practice. By signing the attached Membership Application, you agree to the terms of this Agreement, which represent the entire agreement and understanding between you and the Practice. This Agreement does not provide comprehensive health insurance coverage. It provides only the health care services specifically described. A Comprehensive Disclosure Statement is attached. Junior Membership Application First Name Last Name _____________________________________________________ Date of Birth______________________________________________ Social Security Number ________________________________ Phone: Primary ( ) ____________________ This is my: (please circle one) Home Cell Work Phone: Alternate ( _)___________________ This is my: (please circle one) Home Cell Work E-mail Ad...
Member Acknowledgments. Member hereby acknowledges and agrees as follows:
Member Acknowledgments. You acknowledge that: From time to time, due to emergency situations such as medical emergencies and natural disasters, the Practice may not have a Physician or Nurse Practitioner available. Services offered under this Agreement are beyond the coverage of any insurance plan you have, and the Practice will not seek reimbursement from your plan for services covered under this Agreement. The Practice may xxxx your insurance plan for services provided to you that are not covered by this Agreement, and you and/or your plan will be financially responsible for such services. The annual fee does not affect the co-payments, co-insurance, or deductibles you are required to pay under the terms of your insurance coverage. You agree that you will not seek reimbursement of the annual fee from your insurance plan, unless such fee is covered by your plan. The Practice makes no representations whatsoever that the fees paid under this Agreement are or are not covered by your own health insurance or by other third party plans that might provide you coverage.
