ADVANTAGE PLAN MEMBERSHIP Enrollment Form
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1 Return Form to: Your Nearest Urgent Clinics Medical Care Location or Phone: ADVANTAGE PLAN MEMBERSHIP Enrollment Form Primary Member: Middle Initial: Last Name: Mailing Address: City: State: Zip: SSN: Date of Birth: Address: M F Billing Address: Same as Above Other: Emergency Contact: Name: Phone: Relationship to Patient: Do you have additional members to enroll? Yes No (If yes, complete below.) Page 1 of 6
2 Membership Agreement & Disclosure Statement: Terms - I acknowledge and understand the following: I am voluntarily becoming an Urgent Clinics Medical Care (UCMC) Advantage Plan member and understand that this agreement is non-transferable. I have received the Advantage Plan literature, which describes the types of service provided by UCMC under the plan, the services not provided by UCMC, as well as the general policies of UCMC. I have had the opportunity to ask questions and receive answers regarding the content. This agreement does not provide health insurance coverage nor is it a contract of insurance it provides only the healthcare services specifically described in the UCMC literature. UCMC encourages patients to obtain and maintain insurance for healthcare services not provided by the Urgent Clinics Medical Care Advantage Plan. UCMC will not bill my insurance carrier for any services provided by UCMC as part of this Membership Agreement. The UCMC Advantage Plan will be available to me for treatment immediately. This process includes submitting a completed enrollment form, as well as payment of the first month s membership fees for all enrolled members. I will pay my monthly Advantage Plan membership fee on the due date. In the event that I am unable to pay my fees on time, I understand that I will be charged an administrative fee and that my Advantage Plan membership may be terminated. I am free to cancel this Membership Agreement by providing 60 day written notice to UCMC. Monthly fees will continue to accrue until written cancellation notice is received. If my account is overdue, I am responsible for resolving the outstanding balance prior to my service cancellation. I will be given at least sixty (60) days notice of any fee schedule changes. As a patient of UCMC, my medical treatment is under the supervision of a healthcare provider. UCMC assumes no liability for any act or omission in following the instruction(s) of said provider. I consent to any diagnostic imaging and/or laboratory procedures, medical treatments, or other services rendered under the general and/or special instruction of the provider. My medical record may contain information specific to drug/alcohol abuse and/or addiction, and/or mental health conditions, and/or HIV testing, and/or HIV positive diagnosis, and/or genetic testing. Such diagnosis and treatment information may not be released without my specific consent. I may also withdraw my consent at any time. UCMC will maintain the privacy of my health information as provided in the UCMC Notice of Privacy Practices. There are federal/state and other agencies required to review, and on occasion copy, parts of my medical record for the purpose of assuring an acceptable standard of medical care. I consent to review of my medical record for these purposes alone. I have received a Notice of Privacy Practices, Patient Rights & Responsibilities. Urgent Clinics Medical Care reserves the right to terminate this service with 60 days notice to its membership at any time. Page 2 of 6
3 Member Signature: By my (our) signature(s) below, I (we) have requested to become an Urgent Clinics Medical Care Advantage Plan Member(s) and I (we) agree to the terms outlined in this Membership Agreement & Disclosure Statement. (If the member is a minor or legally incompetent to sign for his/her own medical care, the parent or legal guardian may sign in his/her place for any of the above terms). Primary Member Signature: Date: Signature by: Member Parent Legal Guardian Additional Members Must Also Sign Below: Date: Signature by: Member Parent Legal Guardian Date: Signature by: Member Parent Legal Guardian Date: Signature by: Member Parent Legal Guardian Page 3 of 6
4 Payment Information: Our Urgent Care Advantage Membership Plan allows you to access our clinics unlimited times per month. The Urgent Clinics Medical Care Advantage Membership Plan will be available to you for treatment immediately. This process includes submitting a completed enrollment form and payment of the first month s, $35.00 membership fee for one enrolled member, $68 for two enrolled members, $101 for three enrolled members. For households of four or more, the Advantage Plan membership fee is $126 per month. Each member who visits the clinic for treatment is only charged $10 per visit. There is a onetime enrollment fee of $10 per member. We will accept cash, check, or a credit/debit card for the initial membership fee. The ongoing monthly membership fee will be processed through automatic funds transfer (AFT) from a checking/savings account or through a credit/debit card transaction. Payment of Membership Fees: Please select one of the following payment options for the first month membership fee(s). Cash Enclosed Check Enclosed Bill my Credit/Debit Card (as listed below) Credit Card/Debit Card Card Number: Name on Card: Visa MasterCard Discover Card Expiration Date: Card Billing Address: City: State: Zip: Recurring Monthly Transactions: The ongoing monthly membership fee will be charged to your account on the first business day of the month by the option selected below. 1) Credit Card/Debit Card Visa MasterCard Discover Card Card Number: Expiration Date: 3 digit code Name on Card: Card Billing Address: City: State: Zip: 2) Automatic Funds Transfer (please attach a voided check to this form) Bank Name: Branch: Address: City: State: Zip: Bank Routing Number: Account Number: Type: Checking Savings Name on Account: Membership includes: Office Visits, X-Rays, Simple Fracture Care, Simple Lacerations, Injections (pain, antibiotic, and tetanus), Strains, Sprains, Labs (Urinalysis, Strep Screens, Flu Test, Mono Spots), IV for dehydration or antibiotics, Pediatrics, EKG's, Burns (1st and 2nd degree) and Headaches. Page 4 of 6 Please initial here:
5 Authorization for Recurring Transaction: By signing below, I hereby authorize Urgent Clinics Medical Care to initiate charges to my credit/ debit card or by Automatic Funds Transfer (AFT) withdrawal as indicated above for my monthly membership fee. Charges to my credit/debit card or monthly AFT withdrawals will be on the 1st or the 15th of every month. This authorization to initiate monthly charges to my credit/debit card or monthly AFT withdrawals will continue until Urgent Clinics Medical Care has received written notification from me of my wish to cancel membership in such time and in such manner as to afford Urgent Clinics Medical Care and my financial institution a reasonable opportunity to act on it. I understand that the transaction amount is the total of my membership fee plus the membership fee for all individuals on my account. I understand that Urgent Clinics Medical Care needs to receive a 60 day written notice in order to alter or cancel my scheduled payment; or if I have a credit/debit card number and/or expiration date change. I understand and authorize that a $25.00 fee may be charged to me for declined credit or debit card transactions that are not honored or for insufficient funds. Primary Member Signature: Date: Please tell us how you heard about this program: Employer Friend or Family Website Other For Clinic Use Only Membership Effective Date: Page 5 of 6
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