Common use of Payment Authorization; Execution Clause in Contracts

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 xxxXxxxxxx (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 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 XXXXXX X XXXXXX, M.D. LLC (Signature) (Print Name) By: Xxxxxx Xxxxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXX, M.D. LLC) Program Member from page 1.

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 xxxXxxxxxx 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 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 XXXXXX X XXXXXXPOTOMAC INTERNISTS, M.D. LLC P.C. (Signature) (Print Name) By: Xxxxxx Xxxxx X. Xxxxxx, MD President and Treasurer SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXPOTOMAC INTERNISTS, M.D. LLC) Program Member from page 1.P.C., Xxxxxx)

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 xxxXxxxxxx 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 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 XXXXXX X XXXXXX, M.D. LLC Coral Springs Personalized Care Limited Liability Corp (Signature) (Print Name) By: Xxxxxx Xxxxx X. Xxxxxx, MD President SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXX, M.D. LLC) Program Member from page 1.AGREEMENT

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 xxxXxxxxxx 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 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 XXXXXX X XXXXXX, M.D. LLC (Signature) Xxxxxxx X. Xxxxx, M.D. Inc. (Print Name) By: Xxxxxx XxxxxxXxxxxxx X. Xxxxx, MD M.D. PLEASE RETURN COMPLETED MEMBER AGREEMENT TO THE OFFICE OR FAX TO (000) 000-0000 SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXXxxxxxx X. Xxxxx, M.D. LLC) Program Member from page 1.Inc.)

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 xxxXxxxxxx 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 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 XXXXXX X XXXXXX, M.D. LLC (Signature) Xxxxxxxx Xxxxx-Xxxxx, MD, PA (Print Name) By: Xxxxxx XxxxxxXxxxxxxx Xxxxx-Xxxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXXXXXXXXX XXXXX-XXXXX, M.D. LLC) Program Member from page 1.MD, PA)

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 xxxXxxxxxx 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 CARD NO. CARDHOLDER’S NAME CARD NUMBER EXPIRATION CC ZIP CODE 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”. 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 XXXXXX X XXXXXX, M.D. LLC LC Signature Corporation (Signature) (Print Name) By: Xxxxxx XxxxxxXxxx Xxxxxxxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXX, M.D. LLCLC Signature Corporation) Program Member from page 1.

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 xxxXxxxxxx 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 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 XXXXXX X XXXXXXRBB Personal Care, M.D. LLC (Signature) (Print Name) By: Xxxxxx XxxxxxX. Xxxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXRBB Personal Care, M.D. LLC) Program Member from page 1.

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 xxxXxxxxxx 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 CARD NO. CARDHOLDER’S NAME CARD NUMBER EXPIRATION CC ZIP CODE 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”. 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 XXXXXX X XXXXXX, M.D. LLC (Signature) SINGING SPRINGER, LLC (Print Name) By: Xxxxxx XxxxxxXXXXXX X. XXXXX, MD Member SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXSINGING SPRINGER, M.D. LLC) Program Member from page 1.L.L.C.)

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 xxxXxxxxxx 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 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 XXXXXX X XXXXXXLegacy 8, M.D. LLC (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxxxxx Xxx, MD MD, Member SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXLegacy 8, M.D. LLC) Program Member from page 1.

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 xxxXxxxxxx (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 CARD NO. CARDHOLDER’S NAME CARD NUMBER EXPIRATION CC ZIP CODE 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”. 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 XXXXXX X XXXXXXXxxxxxxx Xxx, M.D. LLC MD (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxxxxx Xxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXXxxxxxxx Xxx, M.D. LLCMD) Program Member from page 1.

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 xxxXxxxxxx (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 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 XXXXXX X XXXXXXXXXX XXXXX, M.D. LLC DO (Signature) (Print Name) By: Xxxxxx XxxxxxXxxx Xxxxx, MD DO SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXXXXX XXXXX, M.D. LLCDO) Program Member from page 1.

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 xxxXxxxxxx (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 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 XXXXXX X XXXXXXCBK SPIRE, M.D. LLC (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxxxx Xxxxxxx, MD Sole Member SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXCBK SPIRE, M.D. LLC) Program Member from page 1.

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 xxxXxxxxxx 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 CARD NO. CARDHOLDER’S NAME CARD NUMBER EXPIRATION CC ZIP CODE 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”. 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 XXXXXX X XXXXXXSRTH, M.D. LLC (Signature) (Print Name) By: Xxxxxx Xxxxxxx Xxxxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXSRTH, M.D. LLC) Program Member from page 1.)

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 xxxXxxxxxx one-fourth (1/4) of the Member Amenities Personalized Care Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER CARD NO. CARDHOLDER’S NAME CARD NUMBER EXPIRATION CC ZIP CODE 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”. 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 XXXXXX X XXXXXX, M.D. LLC DMG Personalized Medicine Inc (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxx X. Xxxxxxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXX, M.D. LLC) Program Member from page 1.AGREEMENT

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 xxxXxxxxxx 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 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”. * Member Amenities Fees will automatically increase three percent (3%) on each annual anniversary of the Effective Date. 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 XXXXXX X XXXXXX, M.D. XXXX XXXXX COMMUNICATIONS LLC (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXX, M.D. XXXX XXXXX COMMUNICATIONS LLC) Program Member from page 1.

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 xxxXxxxxxx 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 CARD NO. CARDHOLDER’S NAME CARD NUMBER EXPIRATION CC ZIP CODE 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”. 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 XXXXXX X XXXXXX, M.D. LLC (Signature) Xxxxxxx X. Xxxxx, M.D. Inc. (Print Name) By: Xxxxxx XxxxxxXxxxxxx X. Xxxxx, MD M.D. PLEASE RETURN COMPLETED MEMBER AGREEMENT TO THE OFFICE OR FAX TO (000) 000-0000 SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXXxxxxxx X. Xxxxx, M.D. LLC) Program Member from page 1.Inc.)

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 xxxXxxxxxx (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 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 XXXXXX X XXXXX XXXXXX, M.D. LLC MD (Signature) (Print Name) By: Xxxxxx Xxxxx Xxxxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXX XXXXXX, M.D. LLCMD) Program Member from page 1.

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 xxxXxxxxxx (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 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 XXXXXX X XXXXXXXXXXX XXXXX, M.D. LLC DO (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxx Xxxxx, MD DO SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXXXXXX XXXXX, M.D. LLCDO) Program Member from page 1.

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 xxxXxxxxxx (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 CARD NO. CARDHOLDER’S NAME CARD NUMBER EXPIRATION CC ZIP CODE 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”. 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 XXXXXX X XXXXXXXXXXX XXXX, M.D. LLC MD (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxx Xxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXXxxxx Xxxx, M.D. LLCMD) Program Member from page 1.

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 xxxXxxxxxx 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 CARD NO. CARDHOLDER’S NAME CARD NUMBER EXPIRATION CC ZIP CODE 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”. 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 XXXXXX X XXXXXX, M.D. LLC (Signature) Xxxxxxxx Xxxxx-Xxxxx, MD, PA (Print Name) By: Xxxxxx XxxxxxXxxxxxxx Xxxxx-Xxxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXXXXXXXXX XXXXX-XXXXX, M.D. LLC) Program Member from page 1.MD, PA)

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 xxxXxxxxxx bill 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 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. 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 XXXXXX X XXXXXXKENTUCKYONE HEALTH MEDICAL GROUP, M.D. LLC INC. (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxxxx Xxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXKENTUCKYONE HEALTH MEDICAL GROUP, M.D. LLCINC.) Program Member from page 1.

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 xxxXxxxxxx (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 CARD NO. CARDHOLDER’S NAME CARD NUMBER EXPIRATION CC ZIP CODE 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”. 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 XXXXXX X XXXXXXKENTUCKYONE HEALTH MEDICAL GROUP, M.D. LLC INC. (Signature) (Print Name) By: Xxxxxx Xxxxxxxx Xxxxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXKENTUCKYONE HEALTH MEDICAL GROUP, M.D. LLCINC.) Program Member from page 1.

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 xxxXxxxxxx (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 CARD NO. CARDHOLDER’S NAME CARD NUMBER EXPIRATION CC ZIP CODE 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”. 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 XXXXXX X XXXXXXXxxxxxxxx XxXxxxx, M.D. LLC MD (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxxxxxx XxXxxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXXxxxxxxxx XxXxxxx, M.D. LLCMD) Program Member from page 1.

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 xxxXxxxxxx 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 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 XXXXXX X XXXXXXXXXXX X. XXXXXXX, M.D. LLC MD (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxx X. Xxxxxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXX, M.D. LLC) Program Member from page 1.

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 xxxXxxxxxx one-fourth (1/4) of the Member Amenities Personalized Care Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER CARD NO. CARDHOLDER’S NAME CARD NUMBER EXPIRATION CC ZIP CODE 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”. 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 XXXXXX X XXXXXXChesapeake Executive Family Care, M.D. LLC PLLC (Signature) (Print Name) By: Xxxxxx Xxxxxxx X. xxXxxxxx-Xxxxxx, MD Secretary /Treasurer SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXXxxxxxx X. xxXxxxxx-Xxxxxx, M.D. LLC) Program Member from page 1.MD)

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 xxxXxxxxxx (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 CARD NO. CARDHOLDER’S NAME CARD NUMBER EXPIRATION CC ZIP CODE 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”. 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 XXXXXX X XXXXXXX. XXXXX, M.D. LLC Xx., MD (Signature) (Print Name) By: Xxxxxx XxxxxxXXXXXX X. XXXXX, Xx., MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXX. XXXXX, M.D. LLCXx., MD) Program Member from page 1.

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 xxxXxxxxxx 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 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 “SignatureMDXxxxxx 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 XXXXXX X XXXXXX, M.D. LLC (Signature) (Print Name) Personalized Care Practice By: Xxxxxx XxxxxxXxxxxxxxx, MD M.D. SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXXxxxxx Xxxxxxxxx, M.D. LLC) Program Member from page 1.M.D., A Medical Corporation)

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 xxxXxxxxxx (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 CARD NO. CARDHOLDER’S NAME CARD NUMBER EXPIRATION CC ZIP CODE 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”. 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 XXXXXX X XXXXXXXXXXX XXXXX, M.D. LLC DO (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxx Xxxxx, MD DO SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXXXXXX XXXXX, M.D. LLCDO) Program Member from page 1.

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 xxxXxxxxxx one-­‐fourth (1/4) of the Member Amenities Personalized Care Fee (that is, $ ) per calendar quarter (3 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 XXXXXX X XXXXXX, M.D. LLC Coral Springs Personalized Care Limited Liability Corp (Signature) (Print Name) By: Xxxxxx Xxxxx X. Xxxxxx, MD President SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXCoral Springs Personalized Care, M.D. LLC) Program Member from page 1.)

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 xxxXxxxxxx 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 CARD NO. CARDHOLDER’S NAME CARD NUMBER EXPIRATION CC ZIP CODE 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”. 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 XXXXXX X XXXXXXXxxxxx X. Xxxxxxxx, M.D. LLC MD (Signature) (Print Name) By: Xxxxxx XxxxxxX. Xxxxxxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXXxxxxx X. Xxxxxxxx, M.D. LLC) Program Member from page 1.MD)

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 xxxXxxxxxx 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 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 XXXXXX X XXXXXXXXXXXXXX X. XXXXX, M.D. LLC MD (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxxxxx X. Xxxxx, MD SCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT Additional Program Members (XXXXXX X XXXXXXXXXXXXXX X. XXXXX, M.D. LLCMD) Program Member from page 1.