Common use of Specialists Coordination Clause in Contracts

Specialists Coordination. CLINIC and Physician shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the CLINIC Physician. Fees as set out below shall apply to the following Member(s), who by signing below agree to the terms and conditions of the KANSAS CITY DIRECT PRIMARY CARE Medical Agreement Form. Member’s Printed Name (Head of Household) Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Cell Phone Preferred email Spouse’s Name Date of Birth (MM/DD/YYYY) Age Spouse’s Home Phone Cell Phone Spouse’s Preferred Email Child’s Name Date of Birth (MM/DD/YYYY) Age Child’s Name Date of Birth (MM/DD/YYYY) Age Child’s Name Date of Birth (MM/DD/YYYY) Age Child’s Name Date of Birth (MM/DD/YYYY) Age Employer-sponsored plan: □ Yearly (Credit/Debit Card) □ Monthly (Credit/Debit Card) I certify that I have read, understand, and agree to the terms set forth in KANSAS CITY DIRECT PRIMARY CARE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: Date: 0-18 years of age $30 per month* 0-18 years of age $65 per month** 19 - 25 years of age $45 per month* 19 - 25 years of age $65 per month** 26 - 64 years of age $65 per month 65+ years of age $90 per month*** Family Rate $140 per month To enjoy the convenience of automated billing, simply complete the Credit/Debit Card Information section below and sign the form. All requested information is required. Upon approval, you will have the option to make monthly payments or set up a monthly auto-deduction. Payments are made directly through our secure link accessed through your electronic statement sent to your email. Your statement will include monthly fees and incidental charges, which you will receive prior to any payments or deductions. Patient(s) Name(s): I authorize KANSAS CITY DIRECT PRIMARY CARE to automatically xxxx and charge the card listed below as specified:

Specialists Coordination. CLINIC MODERN MOBILE MEDICINE and Physician its Physicians shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the CLINIC a MODERN MOBILE MEDICINE Physician. Fees Annual fees as set out below shall apply to the following Member(sPatient(s), who by signing below agree to the terms and conditions of the KANSAS CITY DIRECT PRIMARY CARE MODERN MOBILE MEDICINE Medical Agreement Form. Member’s Printed Name (Head of Household) Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Preferred email Spouse’s Spouse Name Date of Birth (MM/DD/YYYY) Age Spouse’s Home Phone Work Phone Cell Phone Spouse’s Preferred Email Child’s email Print Name Date of Birth (MM/DD/YYYY) Age Child’s Print Name Date of Birth (MM/DD/YYYY) Age Child’s Print Name Date of Birth (MM/DD/YYYY) Age Child’s Name Print NamePreferred Payment Method*□ Yearly (Check Only) Date of Birth (MM/DD/YYYY) Age Employer-sponsored plan: □ Yearly (Credit/Debit Card) □ Monthly (Credit/Debit Card/Check) □ Employer I certify that I have read, understand, and agree to the terms set forth in KANSAS CITY DIRECT PRIMARY CARE MODERN MOBILE MEDICINE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: Date: 0-18 years Individual $79/month After-­‐hours/Weekend Telemedicine Surcharge $30/consultation After-­‐hours/Weekend House Calls Surcharge $200/visit Enrollment Fee $99/individual* Additional Telemedicine Consults $30/each Additional House Calls $99/each *Non-­‐refundable fee. Should your membership lapse or be terminated, the enrollment fee must be paid again for membership to become active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ This agreement (Agreement) is entered into by and between Xxxxxxx Xxxxx MD, LLC d/b/a Modern Mobile Medicine, an Arizona Limited Liability Company, Xx. Xxxxxxx Xxxxx and Xx. Xxxxxxxxxx Xxxxx (collectively “Physicians”), whose principal address is 000 Xxxxxx Xxxxxx #545, Alexandria, Virginia 22305, and , a beneficiary enrolled in Medicare Part B pursuant to Section 4507 of age $30 per month* 0-18 years the Balanced Budget Act of age $65 per month** 19 - 25 years 1997 (Beneficiary), who resides at . The Physicians have informed Patient that Physicians have opted out of age $45 per month* 19 - 25 years the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of age $65 per month** 26 - 64 years of age $65 per month 65+ years of age $90 per month*** Family Rate $140 per month To enjoy the convenience of automated billing, simply complete the Credit/Debit Card Information section below and sign the form. All requested information is required. Upon approval, you will have the option to make monthly payments or set up a monthly auto-deduction. Payments are made directly through our secure link accessed through your electronic statement sent to your email. Your statement will include monthly fees and incidental charges, which you will receive prior to any payments or deductions. Patient(s) Name(s): I authorize KANSAS CITY DIRECT PRIMARY CARE to automatically xxxx and charge the card listed below as specified:Social Security Act.

Specialists Coordination. CLINIC MODERN MOBILE MEDICINE and Physician its Physicians shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the CLINIC a MODERN MOBILE MEDICINE Physician. Fees PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the following Member(sPatient(s), who by signing below agree to the terms and conditions of the KANSAS CITY DIRECT PRIMARY CARE MODERN MOBILE MEDICINE Medical Agreement Form. Member’s Printed Name (Head of Household) Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Preferred email Spouse’s Spouse Name Date of Birth (MM/DD/YYYY) Age Spouse’s Home Phone Work Phone Cell Phone Spouse’s Preferred Email Child’s email Print Name Date of Birth (MM/DD/YYYY) Age Child’s Print Name Date of Birth (MM/DD/YYYY) Age Child’s Print Name Date of Birth (MM/DD/YYYY) Age Child’s Name Print NamePreferred Payment Method* Date of Birth (MM/DD/YYYY) Age Employer-sponsored plan: □ Yearly (Credit/Debit CardCheck Only) □ Monthly (Credit/Debit Card/Check) □ Employer I certify that I have read, understand, and agree to the terms set forth in KANSAS CITY DIRECT PRIMARY CARE MODERN MOBILE MEDICINE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: Date: 0FEE ITEMIZATION – FAMILY PREMIUM MEMBERSHIP Family $379/month After-18 years hours/Weekend House Calls Surcharge $150/visit After-hours/Weekend Telemedicine Surcharge $40/consultation Enrollment Fee $199/family* Additional House Calls $100 off a la carte *Non-refundable fee. Should your membership lapse or be terminated, the enrollment fee must be paid again for membership to become active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ This agreement (Agreement) is entered into by and between Xxxxxxx Xxxxx MD, PLLC d/b/a Modern Mobile Medicine, an Arizona Limited Liability Company, Xx. Xxxxxxx Xxxxx and Xx. Xxxxxxxxxx Xxxxx (collectively “Physicians”), whose principal address is 000 Xxxxxx Xxxxxx #545, Alexandria, Virginia 22305, and _ , a beneficiary enrolled in Medicare Part B pursuant to Section 4507 of age $30 per month* 0-18 years the Balanced Budget Act of age $65 per month** 19 - 25 years of age $45 per month* 19 - 25 years of age $65 per month** 26 - 64 years of age $65 per month 65+ years of age $90 per month*** Family Rate $140 per month To enjoy the convenience of automated billing1997 (Beneficiary), simply complete the Credit/Debit Card Information section below and sign the form. All requested information is required. Upon approval, you will have the option to make monthly payments or set up a monthly auto-deduction. Payments are made directly through our secure link accessed through your electronic statement sent to your email. Your statement will include monthly fees and incidental charges, which you will receive prior to any payments or deductions. Patient(s) Name(s): I authorize KANSAS CITY DIRECT PRIMARY CARE to automatically xxxx and charge the card listed below as specified:who resides at

Specialists Coordination. CLINIC and Physician shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the CLINIC Physician. Fees Annual fees as set out below shall apply to the following Member(sPatient(s), who by signing below agree to the terms and conditions of the KANSAS CITY DIRECT PRIMARY CARE ELEVATED HEALTH Medical Agreement Form. Member’s Printed Name (Head of Household) Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Preferred email Spouse’s Spouse Name Date of Birth (MM/DD/YYYY) Age Spouse’s Home Phone Work Phone Cell Phone Spouse’s Preferred Email Child’s email Print Name Date of Birth (MM/DD/YYYY) Age Child’s Print Name Date of Birth (MM/DD/YYYY) Age Child’s Print Name Date of Birth (MM/DD/YYYY) Age Child’s Print Name Date of Birth (MM/DD/YYYY) Age Employer-sponsored plan: □ Yearly (Credit/Debit Card/Bank Draft) □ Monthly (Credit/Debit Card/Bank Draft) □ Employer I certify that I have read, understand, and agree to the terms set forth in KANSAS CITY DIRECT PRIMARY CARE ELEVATED HEALTH Medical Agreement Form. I further certify that I have received a copy of this form. Signature: Date: 0-18 0-­‐‑19 years of age $30 20 per month* 0-18 20-­‐‑45 years of age $65 75 per month** 19 - 25 46-­‐‑65 years of age $45 95 per month* 19 - 25 years of age $65 per month** 26 - 64 years of age $65 per month 6566+ years of age $90 115 per month* *** Family Rate Patients that require home visits (i.e., nursing homes or assisted living facilities) will be billed an additional $140 10 per month To enjoy month. Patient 1 $ Patient 2 Patient 3 Patient 4 Patient 5 Additional Patients TOTAL RATE $ This agreement (Agreement) is entered into by and between Elevated Health, a California Corporation, Xx. Xxxxxxx Xxxxxxxx (Physician), whose principal address is 00000 Xxxxx Xxxxxxxxx, Xxxxx 000, Xxxxxxxxxx Xxxxx, XX 00000, and , a beneficiary enrolled in Medicare Part B pursuant to Section 4507 of the convenience Balanced Budget Act of automated billing1997 (Beneficiary), simply complete who resides at , , CA . The Physician has informed Patient that Physician has opted out of the Credit/Debit Card Information Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section below and sign of the form. All requested information is required. Upon approval, you will have the option to make monthly payments or set up a monthly auto-deduction. Payments are made directly through our secure link accessed through your electronic statement sent to your email. Your statement will include monthly fees and incidental charges, which you will receive prior to any payments or deductions. Patient(s) Name(s): I authorize KANSAS CITY DIRECT PRIMARY CARE to automatically xxxx and charge the card listed below as specified:Social Security Act.

Specialists Coordination. CLINIC MODERN MOBILE MEDICINE and Physician its Physicians shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the CLINIC a MODERN MOBILE MEDICINE Physician. Fees Annual fees as set out below shall apply to the following Member(sPatient(s), who by signing below agree to the terms and conditions of the KANSAS CITY DIRECT PRIMARY CARE MODERN MOBILE MEDICINE Medical Agreement Form. Member’s Printed Name (Head of Household) Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Preferred email Spouse’s Spouse Name Date of Birth (MM/DD/YYYY) Age Spouse’s Home Phone Work Phone Cell Phone Spouse’s Preferred Email Child’s email Print Name Date of Birth (MM/DD/YYYY) Age Child’s Print Name Date of Birth (MM/DD/YYYY) Age Child’s Print Name Date of Birth (MM/DD/YYYY) Age Child’s Name Print NamePreferred Payment Method*□ Yearly (Check Only) Date of Birth (MM/DD/YYYY) Age Employer-sponsored plan: □ Yearly (Credit/Debit Card) □ Monthly (Credit/Debit Card/Check) □ Employer I certify that I have read, understand, and agree to the terms set forth in KANSAS CITY DIRECT PRIMARY CARE MODERN MOBILE MEDICINE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: Date: 0-18 years Family $199/month After-­‐hours/Weekend Telemedicine Surcharge $20/consultation After-­‐hours/Weekend House Calls Surcharge $150/visit Enrollment Fee $99/family member* Additional Telemedicine Consults $20/each Additional House Calls $75/each *Non-­‐refundable fee. Should your membership lapse or be terminated, the enrollment fee must be paid again for membership to become active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ This agreement (Agreement) is entered into by and between Xxxxxxx Xxxxx MD, LLC d/b/a Modern Mobile Medicine, an Arizona Limited Liability Company, Xx. Xxxxxxx Xxxxx and Xx. Xxxxxxxxxx Xxxxx (collectively “Physicians”), whose principal address is 000 Xxxxxx Xxxxxx #545, Alexandria, Virginia 22305, and , a beneficiary enrolled in Medicare Part B pursuant to Section 4507 of age $30 per month* 0-18 years the Balanced Budget Act of age $65 per month** 19 - 25 years 1997 (Beneficiary), who resides at . The Physicians have informed Patient that Physicians have opted out of age $45 per month* 19 - 25 years the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of age $65 per month** 26 - 64 years of age $65 per month 65+ years of age $90 per month*** Family Rate $140 per month To enjoy the convenience of automated billing, simply complete the Credit/Debit Card Information section below and sign the form. All requested information is required. Upon approval, you will have the option to make monthly payments or set up a monthly auto-deduction. Payments are made directly through our secure link accessed through your electronic statement sent to your email. Your statement will include monthly fees and incidental charges, which you will receive prior to any payments or deductions. Patient(s) Name(s): I authorize KANSAS CITY DIRECT PRIMARY CARE to automatically xxxx and charge the card listed below as specified:Social Security Act.

Specialists Coordination. CLINIC MODERN MOBILE MEDICINE and Physician its Physicians shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the CLINIC a MODERN MOBILE MEDICINE Physician. Fees Annual fees as set out below shall apply to the following Member(sPatient(s), who by signing below agree to the terms and conditions of the KANSAS CITY DIRECT PRIMARY CARE MODERN MOBILE MEDICINE Medical Agreement Form. Member’s Printed Name (Head of Household) Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Preferred email Spouse’s Spouse Name Date of Birth (MM/DD/YYYY) Age Spouse’s Home Phone Work Phone Cell Phone Spouse’s Preferred Email Child’s email Print Name Date of Birth (MM/DD/YYYY) Age Child’s Print Name Date of Birth (MM/DD/YYYY) Age Child’s Print Name Date of Birth (MM/DD/YYYY) Age Child’s Name Print NamePreferred Payment Method*□ Yearly (Check Only) Date of Birth (MM/DD/YYYY) Age Employer-sponsored plan: □ Yearly (Credit/Debit Card) □ Monthly (Credit/Debit Card/Check) □ Employer I certify that I have read, understand, and agree to the terms set forth in KANSAS CITY DIRECT PRIMARY CARE MODERN MOBILE MEDICINE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: Date: 0-18 years Individual $149/month After-­‐hours/Weekend Telemedicine Surcharge $20/consultation After-­‐hours/Weekend House Calls Surcharge $150/visit Enrollment Fee $99/individual* Additional Telemedicine Consults $20/each Additional House Calls $75/each *Non-­‐refundable fee. Should your membership lapse or be terminated, the enrollment fee must be paid again for membership to become active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ This agreement (Agreement) is entered into by and between Xxxxxxx Xxxxx MD, LLC d/b/a Modern Mobile Medicine, an Arizona Limited Liability Company, Xx. Xxxxxxx Xxxxx and Xx. Xxxxxxxxxx Xxxxx (collectively “Physicians”), whose principal address is 000 Xxxxxx Xxxxxx #545, Alexandria, Virginia 22305, and , a beneficiary enrolled in Medicare Part B pursuant to Section 4507 of age $30 per month* 0-18 years the Balanced Budget Act of age $65 per month** 19 - 25 years 1997 (Beneficiary), who resides at . The Physicians have informed Patient that Physicians have opted out of age $45 per month* 19 - 25 years the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of age $65 per month** 26 - 64 years of age $65 per month 65+ years of age $90 per month*** Family Rate $140 per month To enjoy the convenience of automated billing, simply complete the Credit/Debit Card Information section below and sign the form. All requested information is required. Upon approval, you will have the option to make monthly payments or set up a monthly auto-deduction. Payments are made directly through our secure link accessed through your electronic statement sent to your email. Your statement will include monthly fees and incidental charges, which you will receive prior to any payments or deductions. Patient(s) Name(s): I authorize KANSAS CITY DIRECT PRIMARY CARE to automatically xxxx and charge the card listed below as specified:Social Security Act.

Specialists Coordination. CLINIC MODERN MOBILE MEDICINE and Physician its Physicians shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the CLINIC a MODERN MOBILE MEDICINE Physician. Fees Annual fees as set out below shall apply to the following Member(sPatient(s), who by signing below agree to the terms and conditions of the KANSAS CITY DIRECT PRIMARY CARE MODERN MOBILE MEDICINE Medical Agreement Form. Member’s Printed Name (Head of Household) Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Preferred email Spouse’s Spouse Name Date of Birth (MM/DD/YYYY) Age Spouse’s Home Phone Work Phone Cell Phone Spouse’s Preferred Email Child’s email Print Name Date of Birth (MM/DD/YYYY) Age Child’s Print Name Date of Birth (MM/DD/YYYY) Age Child’s Print Name Date of Birth (MM/DD/YYYY) Age Child’s Name Print NamePreferred Payment Method*□ Yearly (Check Only) Date of Birth (MM/DD/YYYY) Age Employer-sponsored plan: □ Yearly (Credit/Debit Card) □ Monthly (Credit/Debit Card/Check) □ Employer I certify that I have read, understand, and agree to the terms set forth in KANSAS CITY DIRECT PRIMARY CARE MODERN MOBILE MEDICINE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: Date: 0-18 years Individual $279/month After-­‐hours/Weekend House Calls Surcharge $99/visit Additional House Calls $50/each Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ This agreement (Agreement) is entered into by and between Xxxxxxx Xxxxx MD, LLC d/b/a Modern Mobile Medicine, an Arizona Limited Liability Company, Xx. Xxxxxxx Xxxxx and Xx. Xxxxxxxxxx Xxxxx (collectively “Physicians”), whose principal address is 000 Xxxxxx Xxxxxx #545, Alexandria, Virginia 22305, and , a beneficiary enrolled in Medicare Part B pursuant to Section 4507 of age $30 per month* 0-18 years the Balanced Budget Act of age $65 per month** 19 - 25 years 1997 (Beneficiary), who resides at . The Physicians have informed Patient that Physicians have opted out of age $45 per month* 19 - 25 years the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of age $65 per month** 26 - 64 years of age $65 per month 65+ years of age $90 per month*** Family Rate $140 per month To enjoy the convenience of automated billing, simply complete the Credit/Debit Card Information section below and sign the form. All requested information is required. Upon approval, you will have the option to make monthly payments or set up a monthly auto-deduction. Payments are made directly through our secure link accessed through your electronic statement sent to your email. Your statement will include monthly fees and incidental charges, which you will receive prior to any payments or deductions. Patient(s) Name(s): I authorize KANSAS CITY DIRECT PRIMARY CARE to automatically xxxx and charge the card listed below as specified:Social Security Act.

Specialists Coordination. CLINIC MODERN MOBILE MEDICINE and Physician its Physicians shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the CLINIC a MODERN MOBILE MEDICINE Physician. Fees Annual fees as set out below shall apply to the following Member(sPatient(s), who by signing below agree to the terms and conditions of the KANSAS CITY DIRECT PRIMARY CARE MODERN MOBILE MEDICINE Medical Agreement Form. Member’s Printed Name (Head of Household) Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Preferred email Spouse’s Spouse Name Date of Birth (MM/DD/YYYY) Age Spouse’s Home Phone Work Phone Cell Phone Spouse’s Preferred Email Child’s email Print Name Date of Birth (MM/DD/YYYY) Age Child’s Print Name Date of Birth (MM/DD/YYYY) Age Child’s Print Name Date of Birth (MM/DD/YYYY) Age Child’s Name Print NamePreferred Payment Method*□ Yearly (Check Only) Date of Birth (MM/DD/YYYY) Age Employer-sponsored plan: □ Yearly (Credit/Debit Card) □ Monthly (Credit/Debit Card/Check) □ Employer I certify that I have read, understand, and agree to the terms set forth in KANSAS CITY DIRECT PRIMARY CARE MODERN MOBILE MEDICINE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: Date: 0-18 years Family $399/month After-­‐hours/Weekend House Calls Surcharge $99/visit Enrollment Fee $199/family* Additional House Calls $50/each *Non-­‐refundable fee. Should your membership lapse or be terminated, the enrollment fee must be paid again for membership to become active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ This agreement (Agreement) is entered into by and between Xxxxxxx Xxxxx MD, LLC d/b/a Modern Mobile Medicine, an Arizona Limited Liability Company, Xx. Xxxxxxx Xxxxx and Xx. Xxxxxxxxxx Xxxxx (collectively “Physicians”), whose principal address is 000 Xxxxxx Xxxxxx #545, Alexandria, Virginia 22305, and , a beneficiary enrolled in Medicare Part B pursuant to Section 4507 of age $30 per month* 0-18 years the Balanced Budget Act of age $65 per month** 19 - 25 years 1997 (Beneficiary), who resides at . The Physicians have informed Patient that Physicians have opted out of age $45 per month* 19 - 25 years the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of age $65 per month** 26 - 64 years of age $65 per month 65+ years of age $90 per month*** Family Rate $140 per month To enjoy the convenience of automated billing, simply complete the Credit/Debit Card Information section below and sign the form. All requested information is required. Upon approval, you will have the option to make monthly payments or set up a monthly auto-deduction. Payments are made directly through our secure link accessed through your electronic statement sent to your email. Your statement will include monthly fees and incidental charges, which you will receive prior to any payments or deductions. Patient(s) Name(s): I authorize KANSAS CITY DIRECT PRIMARY CARE to automatically xxxx and charge the card listed below as specified:Social Security Act.