Virtual Visit/Telemedicine Services. Your Physician or other practitioner at the Practice will provide you virtual visits via telemedicine access, if requested, to the extent that such visits are considered clinically appropriate and practicable, taking into consideration the technology available through the Practice.
Virtual Visit/Telemedicine Services. Your Physician or other practitioner at the Practice will provide you virtual visits via telemedicine access, if requested, to the extent that such visits are considered clinically appropriate and practicable, taking into consideration the technology available through the Practice. SCHEDULE 3 MEMBERSHIP FEES AND PAYMENT PLAN Membership Fees (Please check off your choice): Individual Annual Fee Semi-Annual Quarterly Over 60 $ 3,000.00 $ 1,500.00* $750.00 ** 50 – 60 $2,500.00 $1,250.00* $625.00** 40 – 49 $2,000.00 $1,000.00* $500.00** 35 – 39 $1,600.00 $800.00* $400.00** Under 35 $1,000.00 $500.00* $250.00** Payment Options Annually with no processing cost. *Semi-annually with a 2.5% processing cost applied to each payment. ** Quarterly with a 5% processing cost applied to each payment. Quarterly installments will be charged automatically to the credit card on file on January 1st, April 1st, July 1st, and October 1st each year you are a Member. An initial installment is paid with this Agreement, prorated for the period between the commencement date of this Agreement and the first automatically scheduled installment. Name on card: Card number: Exp. date: Security code: Complete Member Information Name: DOB: Gender: Address: City: State: Zip: Cell Phone: Home Phone: Insurance: Email: SCHEDULE 4 ADDITIONAL TERMS
Virtual Visit/Telemedicine Services. Your Physician or other practitioner at the Practice will provide you virtual visits via telemedicine access, if requested, to the extent that such visits are considered clinically appropriate and practicable, taking into consideration the technology available through the Practice. MEMBERSHIP FEES AND PAYMENT PLAN Membership Fees (Please check off your choice): Annual Semi-Annual Quarterly Monthly Individual $2500 $1250* $625** $208.33*** Couples $4000 $2000* $1000** $333.33*** Payment Options Annually with no processing cost *Semi-annually with a 2.5% processing cost applied to each payment. ** Quarterly with a 5% processing cost applied to each payment. Quarterly installments will be charged automatically to the credit card on file on January 1st, April 1st, July 1st, and October 1st each year you are a Member. An initial installment is paid with this Agreement, prorated for the period between the commencement date of this Agreement and the first automatically scheduled installment. *** Monthly without any processing cost through ACH (Automated Clearing House) Name on card: Card number: Exp. date: Security code: Complete Member Information Name: DOB: Gender: Address: City: State: Zip Code: Cell Phone: Home Phone: Insurance: Email:
Virtual Visit/Telemedicine Services. Your Physician or other practitioner at the Practice will provide you virtual visits via telemedicine access, if requested, to the extent that such visits are considered clinically appropriate and practicable, taking into consideration the technology available through the Practice. MEMBERSHIP FEES AND PAYMENT PLAN Membership Fee: $2,500/year Select Payment Method: Payment Options Annually with no processing cost. Semi-annually with a 2.5% processing cost applied to each payment. Quarterly with a 5% processing cost applied to each payment. Quarterly installments will be charged automatically to the credit card on file on January 1st, April 1st, July 1st, and October 1st each year you are a Member. An initial installment is paid with this Agreement, prorated for the period between the commencement date of this Agreement and the first automatically scheduled installment. Name on card: Card number: Exp. date: Complete Member Information: Name: DOB: Address: Phone: Email: Signature: 3 Semi-annual and quarterly installments will be charged automatically to the credit card on file on January 1st , April 1st , July 1 st ,and October 1 st each year you are a Member. An initial installment is paid with this Agreement, prorated for the period between the commencement date of this Agreement and the first automatically scheduled installment.
