Jeffrey Elfenbein Concierge Internal Medicine

I have engaged Jeffrey Elfenbein Concierge Internal Medicine (Company) and its physician Jeffrey Elfenbein to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning May 9, 2024, and understand that a yearly membership fee is assessed to pay for these non-covered services, amenities, and benefits. As used in this Agreement, the term “Service Year” refers to the 1-year period beginning on May 9, 2024, as well as every 1-year period thereafter.

$2,000/year = Individual = Age 26+
$3,600/year = Couple
$500/year = Each Dependent when Parent is Enrolled (Ages 18 up to 26)

Individuals (Ages 26+) (Required)

Price: $2,000.00

Couples Discount

Applied for the first additional adult over the age of 26.

Price: $0.00

Dependents (Age 18 up to 26 when parent is a member)

Price: $500.00

Annual, semiannual, quarterly, and monthly payment options are available.

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Total members

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Total dependent members

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Total

This Agreement is for non-covered, non-clinical amenities and benefits as described in the Highlights & Details document. I have read and understand this Agreement as well as the Highlights & Details and Frequently Asked Questions documents that are considered a part of this Agreement. I understand that this Agreement can be terminated upon 30 days written notice and that, if the Agreement is terminated, I may receive a prorated refund of the annual fee I paid, based on the number of days that have elapsed in the Service Year (which will be determined by the Company on a case-by-case basis). Such refund may be paid to me within 30 days after termination. Unless the Agreement is terminated as provided in the first paragraph of this Agreement above, it will automatically renew for subsequent Service Years under the same payment terms unless I notify the Company otherwise (or the Company notifies me) within 30 days prior to the next payment due date.

1st Individual (Ages 26+)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number(Required)

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email(Required)

2nd Individual (Ages 26+)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email(Required)

3rd Individual (Ages 26+)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email(Required)

4th Individual (Ages 26+)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email(Required)

Payment Schedule(Required)

I will pay annually

I will pay semianually

I will pay quarterly

I will pay monthly

I understand that the full annual fee will be charged upon receipt of this form and the full annual fee will be charged automatically at 12-month intervals, continually while this Agreement remains in effect.

I understand that one-half of the full annual fee will be charged upon receipt of this form and one-half will be charged automatically at six-month intervals, continually while this Agreement remains in effect.

I understand that one-quarter of the full annual fee will be charged upon receipt of this form and one-quarter will be charged automatically at three-month intervals, continually while this Agreement remains in effect.

I understand that one-twelfth of the full annual fee will be charged upon receipt of this form and one-twelfth will be charged automatically at one-month intervals, continually while this Agreement remains in effect.

Your ANNUAL Payment:

This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged ANNUALLY:

Your SEMIANNUAL Payment:

This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged SEMIANNUALLY:

Your QUARTERLY Payment:

This is the amount that will be charged to your card or pulled from your bank account upon submission of this form, and will subsequently be charged QUARTERLY:

Your MONTHLY Payment:

This is the amount that will be charged to your card or pulled from your bank account upon submission of this form, and will subsequently be charged MONTHLY:

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Payment Method

Credit Card Details

Your card will be charged by Jeffrey Elfenbein Concierge Internal Medicine

Credit Card Type(Required)

Visa

MasterCard

Discover

Card Number(Required)

Expiration Month

Expiration Year

Security Code(Required)

Cardholder Name(Required)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Daytime Phone Number(Required)

Consent(Required)

I authorize Jeffrey Elfenbein Concierge Internal Medicine to automatically charge my credit card the amount(s) indicated on this form.

ACH Option

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Daytime Phone Number(Required)

Bank Name(Required)

Account Type

Routing Number(Required)

Please Confirm Your Routing Number(Required)

Account Number(Required)

Please Confirm Your Account Number(Required)

Consent(Required)

I authorize Jeffrey Elfenbein Concierge Internal Medicine to automatically pull from my bank account the amount(s) indicated on this form.

Digital Signature(Required)

Please type your initials to confirm this agreement.

Is the home address different from billing address(Required)

Yes

No

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

How did you hear about our practice?(Required)

Please elaborate(Required)

Membership Agreement