Add/Remove Member Form
This form is used to add or remove a member from billing. This form can not be used to cancel your membership account.
PRIMARY MEMBER INFORMATION
Primary Member/Guarantor's Name
Billing address
Primary contact number
Format: (000) 000-0000.
Email (a copy of this form will be emailed to this account)
example@example.com
MEMBERSHIP INFORMATION
Is this a corporate account?
Yes
No
Name of Company
Today's date (automatically generated)
I want to
Please Select
Add a member
Remove a current member
Name of the member(s) you want to add/remove
Additional members: Adults $125/month Children: $50/month
Member Agreement
I understand that Personal M.D. Family Healthcare, P.A. (Personal MD) is not a form of insurance and does not meet the criteria required by the
Affordable Care Act (Obamacare). Membership in the Personal MD Medical Care program does not constitute being
insured.
A dependent is a spouse and/or child under 21 or 26 still in school.
All members must live at the same address as the primary employee/member on the account.
I understand that I am responsible for the full fee of additional members.
I understand that I can remove a family member anytime for any reason. The removal must be in writing
and is subject to the billing period used by the primary member.
A pro-rated membership fee must be paid in full before an added member is considered active and eligible to be seen by Personal MD.
I understand that I am financially responsible for all charges accumulated from visits to Personal M.D.
Family Healthcare, P.A.
I understand that Personal M.D. Family Healthcare, P.A. does not accept any insurance of any kind and will not file to your
insurance carrier after your visit to Personal M.D. Family Healthcare, P.A.
I understand that being seen at a Personal MD's office for medical care is consent to receive treatment.
I hereby authorize the physician to treat myself or, if a minor, my child as deemed medically necessary.
I understand that adding/removing members to this account does not change the terms of the agreement made on the Billing Agreement, and I continue to authorize Personal M.D. to continue to charge my credit card or bank account for monthly dues and incident charges accrued on my account.
Corporate Accounts
I understand that the additional fee for family members will be automatically deducted from my paycheck on a schedule determined by my employer.
SIGNATURE OF GUARANTOR/ACCOUNT HOLDER
Today's date and time
Print Name of guarantor
Signature of guarantor
Submit
Should be Empty: