Club Membership Registration Form

Membership Registration

Complete the form below to sign up for our membership service.
Patient or Family Representative Name

First Name Middle Name Last Name
Please provide information about your organization if membership is part of an employee benefit:
Organization

Name of Organization Contract Person First Name Contract Person Last Name
E-mail
Phone Number:

Area Code Phone Number
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Birth Date:

Month Day Year
Membership Start Date: *

Month Day Year
Membership Rules
1. Only legal representatives of the patient or organization may register for membership.

2. Members must pay membership fees by the 3rd of each month. Delinquent payments of 60 days (equivalent to missing 2 consecutive payments) will result in the cancellation of membership.

3. No services will be rendered for members of delinquent accounts until fees have been paid.

4. Membership may be canceled at any time, to commence the following month after the last payment was received. For example, if you pay your May membership payment and cancel your membership on May 8th, you will continue to have services until June 1st.

5. UrgentNP, LLC reserves the right to immediately cancel membership for any real or suspected acts of fraud or any illegal activities by the patient, patient representative, or representative of the organization.

6. Individuals with Medicare or Medicaid benefits are prohibited from Direct Care Membership Plans as these are private pay services.

7. Membership services can not be transferred to a non-member.

8. No refunds will be provided unless services could be rendered due to the inability of UrgentNP, LLC to provide health care services within a reasonable time frame.

9. Patients forfeit the appointment on a membership plan for each appointment he or she fails to cancel or reschedule prior to 24 hours. For example, if you have a total of 3 sick visits on your plan, you "no call no show" for one visit, you now have 2 visits left on your plan.
I have read, understood, and accepted the rules for membership.
Privacy Policy
Please reach out and read our Privacy Policy in order to understand how your information is used and shared, and check below if you accept the policy. This information is listed in detail on the HIPAA Compliant Patient Consent form of the New Patient Forms.
I have read, understood, and accepted the PRIVACY POLICY for membership.
Once you submit your application, we will contact you via email with instructions to make your first payment.

Thank you!
Signature

Clear
Should be Empty:

Membership Registration

Membership Rules

Privacy Policy