Advanced Wellness Membership Agreement

 

This membership agreement ("Agreement") specifies the terms and conditions under which you, the undersigned member ("Member"), may participate in the Grandview Primary Care Advanced Wellness Program ("Program" This agreement will become effective either on the date your Grandview Primary Care Wellness Physician ("Wellness Physician") commences the Program or the date that you execute this Agreement, whichever is later ("Effective Date") 

1.Grandview Primary Care Advanced Wellness Program: The Program's annual fee encompasses the following services ("Services").

• Advanced Wellness Program
  • Advanced cardiopulmonary testing
  • Advanced metabolic testing
  • Extensive wellness plan including customized diet and nutrition plan, and referrals for appropriate cancer screening tests and vaccinations
  • Unlimited in-office visits with your Wellness Physician during regular business hours
  • Unlimited in-office procedures performed by your Wellness Physician
  • Unlimited in-office physical therapy & exercise programming
  • Free membership to Grandview Pro Fitness & Worthington Pro Fitness
  • Complimentary access to the Registered Dietitian on staff
  • Free group fitness classes (during designated hours)

2. Annual Membership Fee: If the annual payment option is chosen, Members will pay an annual fee ("Annual Fee") of $1,999 to Grandview Primary Care at the time of enrollment.

3. Payment of Monthly Membership Fee: Under this option, a payment in the amount of $195 must accompany the application. Should Members choose this option, the Member agrees to pay $195 each month through automatic withdrawals from an account or automatic charges to a credit card maintained by a Member in a financial institution, pursuant to a debit authorization form signed by Member.

4. Renewals and Termination: The Annual Fee covers a period of one (1) year ("Term" Failure to pay the renewal Annual Fee prior to the anniversary of the Effective Date shall result in termination of your membership in the Program. You or GPC may terminate this Agreement at any time upon 30-days' written notice, outside of the six month lock-in period agreed to at the time of signup. If you or GPC terminate this agreement for any reason prior to receiving Services, you will be entitled to a prorated refund of the Annual Fee. If you have received your Services, you will not be eligible fora refund, and you will be responsible for the balance of the remaining monthly or annual fee. Upon GPC's receipt of this Agreement and the Annual Fee, GPC shall have the option, in its sole and absolute discretion, not to accept this Agreement and to return your payment to you for any reason (e.g., due to limitations in practice size Unless otherwise terminated, this Agreement, including, without limitation, the agreement to arbitrate, shall automatically renew for an additional onc-year period upon expiration of each Term.

5. Medical Care Services Excluded from Annual Membership Fee: The Annual Fee specified herein covers only the defined Services. Your Wellness Physician will not seek reimbursement from any insurer or other third party payor for the Services. Except for the Services, you and/or your insurer, as may be the case, will be financially responsible for paying for all healthcare and medical care services received by you from your Wellness Physician and his or her staff. 

6. Email Communications;Privacy: If you wish to send secure email communications to, and receive secure email responses from, your Wellness Physician and/or his or her employees, agents and representatives, you should utilize the secure messaging provided through your Wellness Physician's Electronic Medical Records ("EMR") system. You should be aware that unlike the secure messaging provided through your Wellness Physician's EMR, traditional email is not a secure medium for sending orreceiving potentially sensitive health information. You also acknowledge and understand that email in any form is not a good medium for urgent or time-sensitive communications. In the event that communication is time-sensitive, you must communicate with your Wellness Physician by telephone or in person. You acknowledge and understand that, at the discretion of your "Wellness Physician", your email may become a part of your medical record. 

7. Entire Agreement; Severability: This Agreement contains the entire agreement between the parties and supersedes any prior agreement (written or oral) between the parties. There are no promises or representations other than those which are set out in this Agreement. If any provisions of the Agreement are declared to be unlawful or unenforceable, in whole or part, then the remaining terms and provisions of this Agreement shall remain in full force and effect. 

8. Notices; Electronic Means: Any communication required or permitted to be sent under this Agreement shall be in writing and sent via U.S. mail to the addresses set forth in this Agreement. Any change in address shall be communicated in accordance with the provisions of this section. If executing this Agreement by electronic signature or electronic mark, the parties agree to conduct this transaction by electronic means.

 9. Billing: Initial payments are processed at the time of enrollment. Subsequent payments are charged monthly or annually as elected by the Member. 

10. Governing Law: This Agreement shall be governed by and construed in accordance with the laws of the State of Ohio without regard to Ohio's choice of law provision, except as otherwise provided herein.

Wellness Providers: Shawn C. Bailey MD, Rebecca McClain CNP, Abagail Garcia CNP, Joseph Jacko MD, Sarah Johnson PA-C

Services included in the Advanced Wellness Membership are provided on the Grandview Primary Care website.

 Questions? info@grandviewprimarycare.com

By my signature below, I confirm that I have read, understood, and agree to all terms and conditions set forth in this agreement

Recurring Payment Authorization Form

**Billing does not begin until services have been rendered**

Option 1. Iauthorize Grandview Primary Care & Performance Medicine, LLC to charge my credit card or to make an ACH withdrawal from my bank account indicated upon sign up for $195.00 on the first day of each month for payment of my Advanced Wellness Program membership fee.

Option 2. I authorize Grandview Primary Care & Performance Medicine, LLC to charge my credit card or to make an ACH withdrawal from my bank account indicated upon sign up for $1,999.00 on the day that my membership application is processed.

Option 3. I authorize Grandview Primary Care & Performance Medicine, LLC to charge my credit card or to make an ACH withdrawal from my bank account indicated upon sign up for $850.00. (Four medical office visits are to be rendered within a 12-month period) 

I understand that this authorization will remain in effect until I cancel it in writing, and - agree to notify Grandview Primary Care, LLC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday. understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF)I understand that Grandview Primary Care, LLC may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that aman authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company: so long as the transactions correspond to the terms indicated in this authorization form.