Healthcare Subscription Booklet

Healthcare Subscription Booklet

Subscriber Name:   Provider Name:

1. Subscriber Information

2. Emergency Contact

3. Insurance Information

4. Subscription Plan Details

Select Plan:

I authorize the Provider to automatically renew my subscription and charge the payment method on file according to the selected billing frequency. I understand charges will continue until I submit a cancellation in writing as specified in Section 8.

5. Medical History

Diabetes    Hypertension    Heart Disease    Asthma / COPD

6. Consent and Authorizations

By signing this Subscription Booklet, Subscriber consents to receive routine and emergency healthcare services from Provider within the scope of the chosen subscription plan. Subscriber acknowledges that certain services may not be covered by the subscription and may incur additional charges. Subscriber further authorizes Provider and its agents to obtain and use medical and insurance information as necessary to provide covered services.

Authorization Expiration Date:

I consent to the provision of medical care and treatment by the Provider and authorized clinical staff, including examinations, diagnostic tests, and procedures reasonably necessary for treatment in accordance with accepted medical standards.

I authorize the Provider to disclose my protected health information to health care providers, insurance payors, and other entities as necessary to coordinate care, payment, and health care operations. This authorization is valid until the stated expiration date or revocation in writing.

I consent to receive appointment reminders, billing statements, and other communications electronically at the contact information provided.

I authorize automatic billing in accordance with the billing frequency selected and affirm that I am responsible for any fees not covered by insurance or not included in my subscription plan.

7. HIPAA Acknowledgment

I acknowledge receipt of the Provider's Notice of Privacy Practices and understand my rights with respect to my protected health information, including the right to request restrictions and the right to revoke authorizations to the extent permitted by law. I understand that revocation will not affect disclosures made prior to receipt of the revocation by the Provider.

I acknowledge receipt of the Notice of Privacy Practices.

8. Terms, Fees, Termination and Refunds

Subscription Obligations: Subscriber agrees to pay subscription fees when due. Fees not timely paid may incur interest and/or suspension of services. Provider may modify fees upon thirty (30) days written notice; continuing subscription after notice constitutes acceptance of modified fees.

Termination & Cancellation: Subscriber may cancel without cause by providing written notice as required by Provider. Provider may terminate or suspend services for nonpayment, material breach, or conduct that jeopardizes patient/staff safety. Termination does not relieve Subscriber of obligations for fees accrued prior to termination.

Refunds: Refunds for prepaid periods may be issued at Provider's discretion and will be prorated for services rendered and administrative costs. Services not covered under the subscription (including certain diagnostic procedures and specialist referrals) will be billed separately.

Liability and Indemnity: To the extent permitted by law, Provider's liability for claims arising out of subscription services is limited to direct damages up to the amount of fees paid in the twelve (12) months preceding the claim. Subscriber agrees to indemnify Provider for third-party claims arising from Subscriber's failure to disclose material medical information or misuse of services.

Dispute Resolution: Subscriber and Provider agree to attempt good faith resolution of disputes. If resolution cannot be achieved, disputes will be resolved by binding arbitration under applicable rules, with venue in the jurisdiction where Provider maintains its primary office, unless otherwise required by law.

9. Acknowledgment and Certifications

Subscriber certifies that the information provided in this Subscription Booklet is true, complete, and accurate to the best of Subscriber's knowledge. Subscriber understands that knowingly providing false information may be grounds for termination of services and may have legal consequences.

Right to Withdraw: Subscriber may revoke any authorization provided herein by delivering written notice to Provider; revocation does not affect actions taken in reliance on the authorization prior to receipt of the revocation.

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