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 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 XXXX XXXXX 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 Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here.

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. Signature Print Name By Xxxxx Xxxxxxxxxx, MD Member Name from Member Agreement Acknowledged and Agreed (Initials) Member Name Date of Birth Email Address Home Phone Cell Phone Office Office Phone Fax Mailing Address City State Zip Code Member Name Date of Birth Email Address Home Phone Cell Phone Office Office Phone Fax Mailing Address City State Zip Code Member Name Date of Birth Email Address Home Phone Cell Phone Office 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 XXXX XXXXX COMMUNICATIONS LLCXXXXXXXXXX, MD (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 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 Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefitsbenefits, except for specific specific exceptions not applicable here.

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. 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 XXXX XXXXX COMMUNICATIONS LLCXXXXXXX X. XXXXXXXX, M.D., FACP (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. 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 Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here.

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 bill 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 By Xxxx X. Xxxxxxx, MD 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 demographic non-medical information pertaining to me, my health or my health care me that is maintained by XXXX XXXXX COMMUNICATIONS LLCHEALTHVISIONS MD (the “Entity”). 1. This Authorization concerns the following non-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 personalized care program 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 Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here.

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 bill 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 By Xxxxx Xxxxx, MD 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 me that is maintained by XXXX XXXXX COMMUNICATIONS LLCXXXXX, MD (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 personalized care program 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 Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here.. 1st Member Printed Name Signature of Patient or Representative Date 2nd Member Printed Name Signature of Patient or Representative Date 3rd Member Printed Name Signature of Patient or Representative Date 4th Member Printed Name Signature of Patient or Representative Date If by and through a representative of a Patient

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. Signature By Xxxxx Xxxxx, MD 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 me that is maintained by XXXX XXXXX COMMUNICATIONS LLCXXXXX, MD (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 personalized care program 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 Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here.