Payment Authorization; Execution Clause Samples
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 ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ (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 AMEX CARDHOLDER NAME 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. (Print Name) By: ▇▇▇▇▇▇ ▇▇▇▇▇▇, MD
A. 2ND MEMBER’S NAME B. DATE OF BIRTH ▇. ▇▇▇▇▇▇ ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE
▇. ACKNOWLEDGED AND AGREED INITIALS:
▇. 3RD MEMBER’S NAME B. DATE OF BIRTH ▇. ▇▇▇▇▇▇ ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE
▇. ACKNOWLEDGED AND AGREED INITIALS:
A. 4TH MEMBER’S NAME B. DATE OF BIRTH ▇. ▇▇▇▇▇▇ ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE ▇. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer.
2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA).
3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity.
4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity.
5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Enti...
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 ▇▇▇▇ 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. Signature Print Name Member Name from Member Agreement Acknowledged and Agreed (Initials) Member Name Date of Birth Email Address Home Phone Cell Phone Office Phone Fax Mailing Address City State Zip Code Member Name Date of Birth Email Address Home Phone Cell Phone Office Phone Fax Mailing Address City State Zip Code Member Name Date of Birth Email Address Home Phone Cell Phone Office Phone Fax Mailing Address City State Zip Code 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 ▇▇▇▇ ▇▇▇▇▇ COMMUNICATIONS LLC.
1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer.
2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA).
3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity.
4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity.
5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity.
6. I understand that once information leaves the En...
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 ▇▇▇▇ oneVfourth (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 AMEX CARDHOLDER NAME 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. (Print Name) By: ▇▇▇▇▇ ▇. ▇▇▇▇▇▇, President
Payment Authorization; Execution. Program Member tenders together with this Agreement the Member Amenities Fee and authorizes Personalized Care Practice's designee to bill the Member Amenities Fee per calendar year payable in advance to Program Member's: Visa MC Discover AMEX CVV ZIPCODE
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 ▇▇▇▇ 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 AMEX CARDHOLDER NAME Program Member understands and agrees to send checks for applicable Member Amenities Fees to: 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. LLE Holding PLLC d/b/a LEAMC Personalized Care, PLLC (Print Name) Name: ▇▇▇▇ ▇. ▇▇▇▇▇▇▇, M.D., F.A.C.P. Title: Member 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 ▇. ▇▇▇▇▇▇▇ & Associates Medical Clinic, PLLC (the “Entity”).
1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer.
2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA).
3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity.
4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity.
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 ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ (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 AMEX CARD NO. 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. (Print Name) By: ▇▇▇▇▇▇ ▇. ▇▇▇▇▇, ▇▇., MD
A. 2ND MEMBER’S NAME B. DATE OF BIRTH ▇. ▇▇▇▇▇▇ ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE
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 ▇▇▇▇ oneVfourth (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 AMEX CARD NO. Program Member understands that credit card payments will be processed by ǍdŽnsYǍMD, Inc. and agrees to make payments by check payable to “ ÃdŽnsYÃMD”. 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. (Print Name) By: 'ǦŽdÖǦ >˙ ZǍǍEΣ DD * Signature MD, Inc., a California corporation doing business in the states of North Carolina and South Carolina as CarolinaMD, is not affiliated or associated in any way with the Charlotte-based concierge medical practice, Signature Healthcare, PLLC.
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 ▇▇▇▇ ▇▇▇▇▇▇▇, 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 ▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇
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 ▇▇▇▇ the above Membership Fee: