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. 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: 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 Xxxxx Xxxxx, MD Signature XXXX XXXXX COMMUNICATIONS LLC By Xxxxxx Xxxxx 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 me that is maintained by XXXX XXXXX COMMUNICATIONS LLCXXXXX, MD (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 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. Program Member XXXX X. XXXXXXX, MD Signature XXXX XXXXX COMMUNICATIONS LLC By Xxxxxx XxxxxXxxx X. Xxxxxxx, 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 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”).

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. Program Member Xxxxx Xxxxx, MD Signature XXXX XXXXX COMMUNICATIONS LLC By Xxxxxx Xxxxx 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 me that is maintained by XXXX XXXXX COMMUNICATIONS LLCXXXXX, MD (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 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 XxxxxXXXXXXXXXX, MD Signature Print Name By Xxxxx Xxxxxxxxxx, MD 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 Office Phone Fax Mailing Address City State Zip Code 3rd Member Member Name Date of Birth Email Address Home Phone Cell Phone Office Office Phone Fax Mailing Address City State Zip Code 4th Member Member Name Date of Birth Email Address Home Phone Cell Phone Office 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 LLCXXXXXXXXXX, MD (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 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 XXXXXXX X. XXXXXXXX, M. D., F.A.C.P. Signature XXXX XXXXX COMMUNICATIONS LLC By Xxxxxx Xxxxx, MD Print Name By: Xxxxxxx X. Xxxxxxxx, M.D., FACP 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 LLCXXXXXXX X. XXXXXXXX, M.D., FACP (the “Entity”).