Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx one-fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: Cardholder Name Card Number Expiration Credit Card Zip Code Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. Program Member Signature XXXX XXXXX COMMUNICATIONS LLC By Xxxxxx Xxxxx, MD Print Name Schedule 1 to Personalized Care Membership Agreement Additional Members Member Name from Member Agreement Acknowledged and Agreed (Initials) 2nd Member Member Name Date of Birth Email Address Home Phone Cell Phone Office Phone Fax Mailing Address City State Zip Code 3rd Member Member Name Date of Birth Email Address Home Phone Cell Phone Office Phone Fax Mailing Address City State Zip Code 4th Member Member Name Date of Birth Email Address Home Phone Cell Phone Office Phone Fax Mailing Address City State Zip Code Authorization for Release of Protected Health Information By signing this Authorization, I hereby authorize and direct the use or disclosure of certain information pertaining to me, my health or my health care that is maintained by XXXX XXXXX COMMUNICATIONS LLC.

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx one-fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AME X CARDHOLDER NAME CARD NUMBER EXPIRATION CC ZIP CODE Program Member understands and agrees to send checks for applicable Member Amenities Fees to: Signature MD, 0000 Xxxxxxxxx Xxx, Xxxxx 000, Xxxxxx xxx Xxx, XX 00000. Program Member understands that credit card payments will be processed by Signature MD, Inc. as agent for Xxxxxx Xxxxxxxxx, M.D. and agrees to make payments by check payable to “Xxxxxx Xxxxxxxxx, M.D., A Medical Corporation”. (Signature Page Follows) This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. Program Member (Signature) (Print Name) Personalized Care Practice By: Xxxxxx Xxxxxxxxx, M.D. SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (Xxxxxx Xxxxxxxxx, M.D., A Medical Corporation)

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Membership Fees, or (ii) hereby authorizes Physician’s designee to xxxx one-half (1/2) of the Membership Fee (that is, $ ) semi-annual (6 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NUMBER EXPIRATION CC ZIP CODE Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. Program Member St. Louis Personalized Care, LLC (Signature) (Print Name) By: Xxxxxx Xxxxxx, M.D. SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (St. Louis Personalized Care, LLC) Program Member from page 1.

Payment Authorization; Execution. In order for this Agreement to become effective, please return a signed copy of the Agreement along with the payment (please choose one):  Check for the amount of $1,100 payable to “Foundation for Better Healthcare” is attached; or  Please charge the annual Membership Fee of $1,100 to the following credit / debit / HSA account card Card Number Expiration (MM/YY) Cardholder’s Name as Printed on the Credit Card Verification code Billing address if different from the mailing address listed above Program Member Signature Xxxx Xxxxxxx, M.D., dba Foundation for Better Healthcare Date: Date: Please mail the signed Agreement and payment to: Foundation for Better Healthcare c/o First Internal Medicine 0000 Xxxxx Xxxxxx Xxxxx, Xxxxx 000 Xxxxxxxxx Xxxxxxx, XX 00000 Foundation for Better Healthcare Xxxx Xxxxxxx, M.D. Membership and Personal VIP Care Programs Terms and Conditions of Service

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Membership Fees, or (ii) hereby authorizes Concierge Practice’s designee to xxxx one-‐fourth (1/4) of the Membership Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARD NO. CARDHOLDER’S NAME EXPIRES VERIFICATION # Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. Program Member Xxxxxx Canyon Concierge Medicine, LLC (Signature) (Print Name) By: Xxxxxx Xxxxx, President SCHEDULE 1 to MEMBERSHIP AGREEMENT ADDITIONAL PROGRAM MEMBERS

Payment Authorization; Execution. This Agreement becomes effective upon receipt from Program Member this signed Agreement and either (i) check payable to “Foundation for Better Healthcare” tendered together with this Agreement, or (ii) approved charge to the credit card provided herein to which Program Member hereby authorizes Foundation for Better Healthcare to xxxx the above Membership Fee: Credit Card Number Expiration (MM/YY) Cardholder’s Name as Printed on the Credit Card Verification code Billing address if different from Mailing address listed above Program Member Signature Xxxx Xxxxxxx, M.D., dba Foundation for Better Healthcare Date: Date: Please deliver or mail the signed Agreement and payment to: Foundation for Better Healthcare c/o First Internal Medicine 0000 Xxxxx Xxxxxx Xxxxx, Xxxxx 000 Xxxxxxxxx Xxxxxxx, XX 00000 List of additional Program Members (if applicable, see page 2 of the Agreement) 2nd Member Name Date of Birth E-mail Address Mobile Phone (required) Home Phone Work Phone Mailing address City State ZIP 3rd Member Name Date of Birth E-mail Address Mobile Phone (required) Home Phone Work Phone Mailing address City State ZIP 4th Member Name Date of Birth E-mail Address Mobile Phone (required) Home Phone Work Phone Mailing address City State ZIP 5th Member Name Date of Birth E-mail Address Mobile Phone (required) Home Phone Work Phone

Payment Authorization; Execution Sample Clauses

Filter & Search

Related Clauses

Sub-Clauses