Healthcare Membership Form

HEALTHCARE MEMBERSHIP FORM

Member Information

Member Name:    Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Membership Selection & Billing

Select Membership Type (check one):

Basic Preventive Care Plan — routine visits and telehealth access

Comprehensive Care Plan — includes diagnostics and specialist referrals

Premium Family Plan — covers member and dependents as listed on this form

Billing Method:

Recurring card payment (card details provided and stored securely by practice)

Bill primary insurance (member remains financially responsible for non-covered services)

Other:

Consent, Authorizations, and Acknowledgments

By signing this form the member authorizes clinicians, staff, and billing agents to provide and coordinate healthcare services reasonably necessary for diagnosis and treatment. The member acknowledges that no guarantee of outcome is made and that all treatments carry inherent risks. The member further acknowledges the right to withdraw consent at any time except to the extent that services have already been provided.

Assignment of Benefits: The member authorizes assignment of insurance benefits to the practice for services rendered. The member accepts responsibility for payment of co-payments, deductibles, coinsurance, and services not covered by insurance, including any collection costs, interest, or legal fees incurred in the recovery of unpaid balances.

Release of Information: The member authorizes release of medical information necessary to process claims, referrals, and care coordination. This authorization includes the release of protected health information to other healthcare providers, labs, and payors as necessary for treatment, payment, and healthcare operations.

HIPAA & Communication Preferences

Acknowledgment of Privacy Practices: I acknowledge that I have received, reviewed, or been offered the practice's Notice of Privacy Practices describing how my protected health information may be used or disclosed.

Preferred Methods for Appointment Reminders and Communications (check all that apply):

Phone call

SMS / Text message

Email

Terms, Termination, and Refunds

Membership Term: Memberships continue until terminated in writing by the member or the practice. The practice reserves the right to terminate membership for non-payment, fraudulent information, or actions that impair the practice's ability to provide care. Refunds of prepaid fees, if any, are at the sole discretion of the practice and are subject to proration for services received.

Amendment of Agreement: The practice may amend membership terms with advance notice to the member; continued use of services after notice constitutes acceptance of amended terms.

Additional Authorizations

Acknowledgment and Signature

By signing below, I certify that the information provided is true and complete to the best of my knowledge. I authorize the practice to provide treatment, to release medical information for care and billing purposes, and to bill my insurance and/or process payments as indicated above. I understand my financial obligations and consent to the terms set forth in this membership form.

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