CONCIERGE MEDICAL PRACTICE Membership Agreement Wellesley Primary Care Medicine, PC Step 1 of 6 - Agreement 16% I have engaged Wellesley Primary Care Medicine, PC (“WPCMED”),to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning July 27, 2024. I understand that this Agreement will renew automatically following the end of each one-year period unless I provide WPCMED with a written notice of non-renewal at least 30 days before the end of a renewal year. I further understand that I will be required to pay a yearly membership fee at the start of each renewal term for the non- covered services, amenities and benefits. As used in this Agreement, the term “Service Year” refers to the one-year period beginning on July 27, 2024, as well as every one-year renewal period thereafter. $2,200/year = Individual (age 26 and over as of date of enrollment) $3,960/year = Adult Couple (age 26 and over as of date of enrollment) Dependents (ages 18-26) included when parent is a member. Individuals (age 26 and over as of date of enrollment)0123456Individuals (ages 18-26 as of date of enrollment)01234567HiddenTotal members(will be hidden, for logic only)26 and over Price: $0.00 Couple Discount Price: $0.00 18 - 26 Price: $0.00 Total $0.00 This Agreement is for non-covered, non-clinical amenities and benefits as described in the Highlights & Details (H&D) document. I have read and understand this Agreement as well as the Highlights & Details (H&D) and Frequently Asked Questions (FAQ) 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 will 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 WPCMED on a case-by-case basis). Such refund will 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 practice otherwise (or the practice notifies me) at least 30 days of the next payment due date. 1st Individual (age 26 and over)My Preferred Physician is:* Alan Glaser, MD Maryann Shea, MD Laura Rabideau, MD Name* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?* Yes No Email* 2nd Individual (age 26 and over)My Preferred Physician is:* Alan Glaser, MD Maryann Shea, MD Laura Rabideau, MD Name* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?* Yes No Email* 3rd Individual (age 26 and over)My Preferred Physician is:* Alan Glaser, MD Maryann Shea, MD Laura Rabideau, MD Name* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?* Yes No Email* 4th Individual (age 26 and over)My Preferred Physician is:* Alan Glaser, MD Maryann Shea, MD Laura Rabideau, MD Name* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?* Yes No Email* 5th Individual (age 26 and over)My Preferred Physician is:* Alan Glaser, MD Maryann Shea, MD Laura Rabideau, MD Name* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?* Yes No Email* 6th Individual (age 26 and over)My Preferred Physician is:* Alan Glaser, MD Maryann Shea, MD Laura Rabideau, MD Name* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?* Yes No Email* 1st Dependent (age 18-26)My Preferred Physician is:* Alan Glaser, MD Maryann Shea, MD Laura Rabideau, MD Name* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?* Yes No Email* 2nd Dependent (age 18-26)My Preferred Physician is:* Alan Glaser, MD Maryann Shea, MD Laura Rabideau, MD Name* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?* Yes No Email* 3nd Dependent (age 18-26)My Preferred Physician is:* Alan Glaser, MD Maryann Shea, MD Laura Rabideau, MD Name* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?* Yes No Email* 4th Dependent (age 18-26)My Preferred Physician is:* Alan Glaser, MD Maryann Shea, MD Laura Rabideau, MD Name* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?* Yes No Email* 5th Dependent (age 18-26)My Preferred Physician is:* Alan Glaser, MD Maryann Shea, MD Laura Rabideau, MD Name* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?* Yes No Email* 6th Dependent (age 18-26)My Preferred Physician is:* Alan Glaser, MD Maryann Shea, MD Laura Rabideau, MD Name* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?* Yes No Email* 7th Dependent (age 18-26)My Preferred Physician is:* Alan Glaser, MD Maryann Shea, MD Laura Rabideau, MD Name* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?* Yes No Email* Payment Schedule* I will pay annually I will pay semiannually I will pay quarterly I understand 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, from my renewal date, while this Agreement remains in effect.I understand one-half of the annual fee will be charged upon receipt of this form and one-half will be charged automatically at six-month intervals, continually, from my renewal date, while this Agreement remains in effect.I understand one-quarter of the annual fee will be charged upon receipt of this form and one-quarter will be charged automatically at three-month intervals, continually, from my renewal date, while this Agreement remains in effect.Your ANNUAL 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 ANNUALLY:Your SEMIANNUAL 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 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:HiddenPayment Methodcredit cardACHCredit Card DetailsCredit Card Type* Visa Master Card AMEX Discover Card Number* Card Number* Expiration MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberExpiration Year202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050Security Code* Security Code* Cardholder Name* Billing Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Daytime Phone Number*Consent* I authorize WPCMED to automatically charge my credit card the amount(s) indicated on this form. ACH OptionBilling Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Daytime Phone Number*Bank Name* Account TypeBusinessPersonalRouting Number* Please Confirm Your Routing Number* Account Number* Please Confirm Your Account Number* Consent* I authorize WPCMED to automatically pull from my bank account the amount(s) indicated on this form. Digital Signature*Please type your initials to confirm this agreement. Is the home address different from billing address* Yes No Home Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How did you hear about our practice?*I am a Current PatientI am a Former PatientInsurance ProviderInternet SearchPatient ReferralPhysician ReferralPrint AdvertisingOtherUntitled First Choice Second Choice Third Choice Δ
