Common use of Membership Plan Clause in Contracts

Membership Plan. A Membership Plan includes concierge access to the NP via direct phone and text line; a reduced cost on all visits of $39/visit (medical, HeartMath, acupressure, NET; in-person or virtual); free B12 injections; wholesale plus shipping costs of supplements via Fullscript; lab and imaging orders and review; prescription medications if necessary; referrals and communication to specialists; priority and after hours (if available) appointments; form completion. The cost of labs, imaging, medication, and other specialists’ fees are not included in the membership. FCIM cannot guarantee insurance coverage of any ordered service. With the exception of prior authorization requirements for imaging and medication, FCIM will not contact your health insurance company regarding costs of services ordered by FCIM, whether or not they have been performed, including recommended labs. Membership plans are 12-month contracts with a consecutive 6-month minimum participation. If You elect a Membership Plan, a payment schedule must be set up at the time of election of plan. Charges are automatically deducted from the credit card on file at the time chosen at your initial visit and monthly thereafter on the date of the month closes to the date of your first appointment (1st, 5th, 10th, 15th, 25th, or 30th). Appointments do not carry over after the anniversary of your first visit. Memberships cannot be backdated to include previous appointments. Twenty-four hours’ notice is required for cancellation of an appointment. There is a $150 cancellation fee for cancellation of an initial consult, and a $50 fee for cancellation of other appointments if cancellation occurs within the twenty-four hours prior to the appointment. If You cancel this agreement prior to the end of the one-year term, You will be charged for the remaining consecutive 6-month commitment if not previously fulfilled. Requests for cancellation of membership and refund will be dealt with on an individual basis. FCIM does not accept insurance. If requested, an invoice will be given to the patient to submit to the commercial insurance company. FCIM will not intervene with the commercial insurance company. Persons with Medicare and Medicaid are not eligible for reimbursement. A la carte Appointments: Payments must be made at the time of service. Unless otherwise requested, payment will be made by a charge to the credit card on file. Twenty-four hours’ notice is required for cancellation of an appointment. There is a $150 cancellation fee for cancellation of an initial consult, and a $50 fee for cancellation of other appointments if cancellation occurs within the twenty-four hours prior to the appointment. FCIM does not accept insurance. If requested, an invoice will be given to the patient to submit to the commercial insurance company. FCIM will not intervene with the commercial insurance company. Persons with Medicare and Medicaid are not eligible for reimbursement. Plan Chosen: ¨ A la carte appointments ¨ Membership Plan (Start Date: Rate: ) First Coast Integrative Medicine 00000 Xxxxxxxx Xx., Xxx 000‌‌ Xxxxxxxxxxxx, XX 00000 Phone (000) 000-0000 Fax (000) 000-0000 xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx

Membership Plan. A Membership Plan includes concierge access to the NP via direct phone an initial consultation and text lineadditional visits per year (may be done virtually); a reduced cost HeartMath biofeedback; 50% discounts on all visits of $39/visit (medical, HeartMath, acupressure, NET; in-person or virtual)acupressure visits; free B12 injections; wholesale plus shipping costs of supplements via Fullscript(excludes Masaya CBD); lab and imaging orders and review; prescription medications if necessary; referrals and communication to specialists; priority . It also includes 24/7 phone and after hours (if available) appointments; form completiontext access to the NP. The cost of labs, imaging, medication, and other specialists’ fees are not included in the membership. FCIM cannot guarantee insurance coverage of any ordered service. With the exception of prior authorization requirements for imaging and medication, FCIM will not contact your health insurance company regarding costs of services ordered by FCIM, whether or not they have been performed, including recommended labs. Membership plans are 12-month contracts contract with a consecutive 6-6- month minimum participation. If You elect a Membership Plan, a payment schedule must be set up at the time of election of plan. Charges are automatically deducted from the credit card on file at the time chosen at your initial visit and monthly thereafter on the date of the month closes to the date of your first appointment (1st, 5th, 10th, 15th, 25th, or 30th). Appointments do not carry over after the anniversary of your first visit. Memberships cannot be backdated to include previous appointments. Twenty-four hours’ notice is required for cancellation of an appointment. There is a $150 cancellation fee for cancellation of an initial consult, and a $50 fee for cancellation of other appointments if cancellation occurs within the twenty-four hours prior to the appointment. If You cancel this agreement prior to the end of the one-year term, You will be charged for the remaining consecutive 6-month commitment if not previously fulfilled. Requests for cancellation of membership and refund will be dealt with on an individual basis. FCIM does not accept insurance. If requested, an invoice will be given to the patient to submit to the commercial insurance company. FCIM will not intervene with the commercial insurance company. Persons with Medicare and Medicaid are not eligible for reimbursement. A la carte Appointments: Payments must be made at the time of service. Unless otherwise requested, payment will be made by a charge to the credit card on file. Twenty-four hours’ notice is required for cancellation of an appointment. There is a $150 cancellation fee for cancellation of an initial consult, and a $50 fee for cancellation of other appointments if cancellation occurs within the twenty-four hours prior to the appointment. FCIM does not accept insurance. If requested, an invoice will be given to the patient to submit to the commercial insurance company. FCIM will not intervene with the commercial insurance company. Persons with Medicare and Medicaid are not eligible for reimbursement. Plan Chosen: ¨ A la carte appointments ¨ Membership Plan (Start Date: Rate: ) First Coast Integrative Medicine 00000 Xxxxxxxx Xx., Xxx 000‌‌ Xxxxxxxxxxxx, XX 00000 Phone (000) 000-0000 Fax (000) 000-0000 xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx

Membership Plan. A Membership Plan includes concierge access to the NP via direct phone an initial consultation and text lineadditional visits per year (may be done virtually); a reduced cost HeartMath biofeedback; 50% discounts on all visits of $39/visit (medical, HeartMath, acupressure, NET; in-person or virtual)acupressure visits; free B12 injections; wholesale plus shipping costs of supplements via Fullscript(excludes Masaya CBD); lab and imaging orders and review; prescription medications if necessary; referrals and communication to specialists; priority . It also includes 24/7 phone and after hours (if available) appointments; form completiontext access to the NP. The cost of labs, imaging, medication, and other specialists’ fees are not included in the membership. FCIM cannot guarantee insurance coverage of any ordered service. With the exception of prior authorization requirements for imaging and medication, FCIM will not contact your health insurance company regarding costs of services ordered by FCIM, whether or not they have been performed, including recommended labs. Membership plans are 12-month contracts contract with a consecutive 6-6- month minimum participation. If You elect a Membership Plan, a payment schedule must be set up at the time of election of plan. Charges are automatically deducted from the credit card on file at the time chosen at your initial visit and monthly thereafter on the date of the month closes to the date of your first appointment (1st, 5th, 10th, 15th, 25th, or 30th). Appointments do not carry over after the anniversary of your first visit. Memberships cannot be backdated to include previous appointments. Twenty-four hours’ notice is required for cancellation of an appointment. There is a $150 cancellation fee for cancellation of an initial consult, and a $50 fee for cancellation of other appointments if cancellation occurs within the twenty-four hours prior to the appointment. If You cancel this agreement prior to the end of the one-year term, You will be charged for the remaining consecutive 6-month commitment if not previously fulfilled. Requests for cancellation of membership and refund will be dealt with on an individual basis. FCIM does not accept insurance. If requested, an invoice will be given to the patient to submit to the commercial insurance company. FCIM will not intervene with the commercial insurance company. Persons with Medicare and Medicaid are not eligible for reimbursement. A la carte Appointments: Payments must be made at the time of service. Unless otherwise requested, payment will be made by a charge to the credit card on file. Twenty-four hours’ notice is required for cancellation of an appointment. There is a $150 cancellation fee for cancellation of an initial consult, and a $50 fee for cancellation of other appointments if cancellation occurs within the twenty-four hours prior to the appointment. FCIM does not accept insurance. If requested, an invoice will be given to the patient to submit to the commercial insurance company. FCIM will not intervene with the commercial insurance company. Persons with Medicare and Medicaid are not eligible for reimbursement. Plan Chosen: ¨ A la carte appointments ¨ Membership Plan (Start Date: Rate: ) First Coast Integrative Medicine 00000 Xxxxxxxx Xx.Xxxxx, Xxx 000‌‌ 000‌ Xxxxxxxxxxxx, XX 00000 Phone (000) 000-0000 Fax EIN: 00-0000000 NPI: 0000000000 (Xxxxx Xxxxxx, DNP) Appendix 2 Medicare Opt Out Agreement This agreement (“Agreement”) is entered into by and between Xxxxx Xxxxxx, DNP, LLC/dba First Coast Integrative Medicine (FCIM), whose principal medical office is located at 00000 Xxxxxxxx Xx, Xxx 000) 000-0000 xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx, Xxxxxxxxxxxx, XX 00000, and , a beneficiary enrolled in Medicare Part B (“Beneficiary”), who resides at , , Florida/Hawaii .

Membership Plan. A Membership Plan includes concierge access to the NP via direct phone and text line; a reduced cost on all visits of $39/visit (medical, HeartMath, acupressure, NET; in-person or virtual); free B12 injections; wholesale plus shipping costs of supplements via Fullscript; lab and imaging orders and review; prescription medications if necessary; referrals and communication to specialists; priority and after hours (if available) appointments; form completion. The cost of labs, imaging, medication, and other specialists’ fees are not included in the membership. FCIM cannot guarantee insurance coverage of any ordered service. With the exception of prior authorization requirements for imaging and medication, FCIM will not contact your health insurance company regarding costs of services ordered by FCIM, whether or not they have been performed, including recommended labs. Membership plans are 12-month contracts with a consecutive 6-month minimum participation. If You elect a Membership Plan, a payment schedule must be set up at the time of election of plan. Charges are automatically deducted from the credit card on file at the time chosen at your initial visit and monthly thereafter on the date of the month closes to the date of your first appointment (1st, 5th, 10th, 15th, 25th, or 30th). Appointments do not carry over after the anniversary of your first visit. Memberships cannot be backdated to include previous appointments. Twenty-four hours’ notice is required for cancellation of an appointment. There is a $150 cancellation fee for cancellation of an initial consult, and a $50 fee for cancellation of other appointments if cancellation occurs within the twenty-four hours prior to the appointment. If You cancel this agreement prior to the end of the one-year term, You will be charged for the remaining consecutive 6-month commitment if not previously fulfilled. Requests for cancellation of membership and refund will be dealt with on an individual basis. FCIM does not accept insurance. If requested, an invoice will be given to the patient to submit to the commercial insurance company. FCIM will not intervene with the commercial insurance company. Persons with Medicare and Medicaid are not eligible for reimbursement. A la carte Appointments: Payments must be made at the time of service. Unless otherwise requested, payment will be made by a charge to the credit card on file. Twenty-four hours’ notice is required for cancellation of an appointment. There is a $150 cancellation fee for cancellation of an initial consult, and a $50 fee for cancellation of other appointments if cancellation occurs within the twenty-four hours prior to the appointment. FCIM does not accept insurance. If requested, an invoice will be given to the patient to submit to the commercial insurance company. FCIM will not intervene with the commercial insurance company. Persons with Medicare and Medicaid are not eligible for reimbursement. Plan Chosen: ¨ 🞎 A la carte appointments ¨ 🞎 Membership Plan (Start Date: Rate: ) First Coast Integrative Medicine 00000 Xxxxxxxx Xx.Xxxxx, Xxx 000‌‌ 000 Xxxxxxxxxxxx, XX 00000 Phone (000) 000-0000 Fax EIN: 00-0000000 NPI: 0000000000 (Xxxxx Xxxxxx, DNP) Appendix 2 Medicare Opt Out Agreement This agreement (“Agreement”) is entered into by and between Xxxxx Xxxxxx, DNP, LLC/dba First Coast Integrative Medicine (FCIM), whose principal medical office is located at 00000 Xxxxxxxx Xx, Xxx 000) 000-0000 xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx, Xxxxxxxxxxxx, XX 00000, and , a beneficiary enrolled in Medicare Part B (“Beneficiary”), who resides at , , Florida/Hawaii .