Texas Family Physicians Medical Membership Program
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1 Texas Family Physicians Medical Membership Program Thank you for choosing to become a member of the Texas Family Physicians Medical Membership Program (the Membership Program ). This packet outlines the terms and conditions relating to the Membership Program and will serve as the agreement under which we provide you our services. Please review this information in full and complete those sections that require your input. If you have any questions please do not hesitate to contact us. Once complete, please sign this agreement and return it to us at your earliest convenience. 1. Membership. By signing this agreement and returning it to Texas Family Physicians, you agree to become a member of the Membership Program subject to the attached terms and conditions. Your membership shall become effective immediately as of the date this packet is signed and submitted back to Texas Family Physicians and shall continue in effect until terminated by either of you or Texas Family Physicians as allowed by the terms and conditions. 2. Membership Services. The services available under the Membership Program (the Membership Services ) are described in the Membership Services Attachment attached hereto. Texas Family Physicians may modify, add, or discontinue Membership Services at any time, as it may choose in its sole discretion. Texas Family Physicians shall provide at least sixty (60) days written notice prior to making any changes to the Membership Services. 3. Membership Options and Fees. You may select an individual membership or a family membership. A family is defined as a head of household and their dependents. As such, a family membership may only include those individuals living in one household who are dependents on the head of the household. Please select your membership and payment type below. You agree to pay the membership fee in accordance with the Membership Program option selected below. Membership Fees can be paid in one single annual payment or in monthly installments, both in the amounts set forth above. If you select monthly payments, you hereby authorize Texas Family Physicians to automatically charge the credit card identified below in the amount set forth above. Such charges shall take place on the first (1 st ) day of each calendar month. To cancel such automatic payment, please notify Texas Family Physician at least three (3) business days in advance of the upcoming charge. However, cancelling an automatic payment does not terminate your participation in the Membership Program. Membership Type Annual Fee Monthly Fee Individual $1,200/Year $100/Month Family $2,400/Year $200/Month 2 Person Family $1,800/Year $150/Month You understand and acknowledge that the Membership Fee is compensation solely for membership in the Membership Program and for the Membership Services, and does not include any medical services provided to you by Texas Family Physicians that are not expressly included in the Membership Services. This means that Texas Family Physicians may bill your insurance for services that are not offered under the Membership Program. You shall be responsible to separately pay, either individually or through a health benefit plan, for all medical services rendered by Texas Family Physicians that are not included in the Membership Services.
2 CREDIT CARD INFORMATION CARDHOLDER S NAME CARD NUMBER CV NUMBER EXPIRATION DATE ACH DEBIT AGREEMENT as an alternative to credit card payment on the next page of this document 4. Payment for Non-Membership Services. As stated above, you understand that the Membership Fee is compensation solely for the Membership Services. You may elect to pay for any non-membership Services through your health plan or, alternatively, you may elect to instead pay for any non-membership Services yourself. However, if you are a Medicare or Medicaid beneficiary, you may not elect to self-pay for non-membership Services. Please make your selection below. This selection may be changed at any time. I elect to pay for non-membership Services through my health plan and authorize the release of all necessary information to such plan as necessary. I understand that I may be personally responsible for payment of certain fees for services not covered by my plan. I elect to self-pay for all non-membership services. I represent that I have read and understood the Self-Pay Agreement provided to me by Texas Family Physicians. I understand that I may not select this option if I am a beneficiary of the Medicare of Medicaid program. By signing below you attest that you have read and understood the entirety of this packet, including the attached terms and conditions, and that all information you have provided in this packet is true and accurate as of the date completed. Signature: Date: Printed Name:
3 AUTOMATED CLEARING HOUSE (ACH) CUSTOMER ORIGINATION AGREEMENT SCHEDULE H AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS) I (we) hereby authorize, hereinafter called COMPANY, to debit entries to my (our) account indicated below and the Bank named below, hereinafter called BANK, to debit the same to such account. I (we) acknowledge the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. (Bank Name) (Branch) (Address) (City, State) (Zip) Type of Acct: Checking Savings (Routing/Transit Number) (Account Number) (Amount) (Frequency of Occurrence: Monthly, Quarterly, etc.) This authority is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and manner as to afford COMPANY and BANK a reasonable opportunity to act on it. (Print Individual Name) (Print Individual ID Number) (Signature) (Date) (Print Individual Name) (Print Individual ID Number) (Signature) (Date) PLEASE ATTACH COPY OF VOIDED CHECK TO THIS FORM
4 Member Profile Primary Member Divorced Widowed Business Preferred Pharmacy Name Preferred Pharmacy Address Preferred Pharmacy Phone *skip to Terms and Conditions if this is an individual membership
5 Family Member 1 Divorced Widowed Business Preferred Pharmacy Name City, State Pharmacy Phone
6 Family Member 2 Divorced Widowed Business Preferred Pharmacy Name City, State Pharmacy Phone
7 Family Member 3 Divorced Widowed Business Preferred Pharmacy Name City, State Pharmacy Phone
8 Family Member 4 Divorced Business Widowed Preferred Pharmacy Name City, State Pharmacy Phone *Please contact Texas Family Physicians if more Family Member Profile sheets are needed.
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Patient Information PATIENT NAME: DOB: AGE: ADDRESS: ZIP CODE: EMPLOYER NAME: WORK PHONE: RACE: SEX: Male Female PRIMARY DOCTOR: NAME: TELEPHONE#
Patient Information Welcome to our office. We appreciate the confidence that you have placed with us regarding your healthcare needs. To assist us in serving you, please complete the following forms as
Advanced Endocrinology and Weight Management Ritu Malik MD
PATIENT INFORMATION PERMANENT ADDRESS EMAIL: PHONE: Home Work Cell SEX M F AGE MARITAL STATUS M S D W SPOUSE NAME PATIENT SOCIAL SECURITY - - OCCUPATION EMPLOYER EMPLOYER ADDRESS EMERGENCY CONTACT NAME
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Automated Minimum Distribution Request Governmental 457(b) Plan Refer to the Minimum Distribution Information and Instructions for assistance in completing this form. Use blue or black ink only. Kern County
CREDIT INFORMATION SEND US YOUR CREDIT APPLICATION AND RESALE CARD AND WE WILL EXTEND YOU $ INSTANT CREDIT FOR USE ON YOUR FIRST ORDER ONLY.
Office: (800) 854-6404 Fax: (714) 238-6222 Email: wschul@5daybf.com CREDIT INFORMATION SEND US YOUR CREDIT APPLICATION AND RESALE CARD AND WE WILL EXTEND YOU $500.00 INSTANT CREDIT FOR USE ON YOUR FIRST
AccessCUBICIN Enrollment Form
Services Requested REQUIRED Choose the Services that are being Requested INSTRUCTIONS FOR COMPLETING THIS FORM Patient Information REQUIRED Include the primary contact; if other than the patient, include
Account Maintenance Form
LONESTAR 529 PLAN SM Account Maintenance Form INSTRUCTIONS Print clearly in all CAPITAL LETTERS using blue or black ink. When requested, please color in circles completely. For example: not not The following
PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address
PATIENT REGISTRATION (Please Print) Date Name (Last) (First) (MI) Clinician Social Security # Address City State Zip Email Address Home Phone ( ) Mobile/Alt. Phone ( ) Work Phone ( ) PLEASE IDENTIFY WHICH