ProPartners Healthcare, P.A.
Direct Primary Care Member Agreement

Appendix B
Member Information Sheet

 

This Agreement is entered into on *
This Agreement is entered into on
Enter the FIRST DAY of the current month OR the FIRST DAY of one of the following two months.
Enter First Name and Middle Initial in "First Name" Field
Member Name *
Member Name
Home Address *
Home Address
Date of Birth *
Date of Birth
Parent/Guardian Name
Parent/Guardian Name
If Member is younger than 18 years of age, this Agreement is being entered into on behalf of Member by the following Parent or Legal Guardian:
Parent/Guardian Address (if different than Member)
Parent/Guardian Address (if different than Member)
Preferred Phone *
Preferred Phone
Emergency contact, your relationship and contact phone number
Preferred Method of Communication *
Preferred Physician *
Billing Information
Billing Address for Card *
Billing Address for Card
(format mm/yy)
Please charge my card on the: *

By selecting the "Submit" button above, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "Submit" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide PPHC with instructions via this online Agreement, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature, acceptance and agreement as if actually signed by you in writing.

The monthly Membership Fee is based on age at beginning of month:

Member age Under 20 20s 30s 40s 50s 60s 70+
Monthly fee $30* $40 $55 $70 $85 $105 $125
*Members under 18 years of age require participation of at least one parent or legal guardian.