Membership AgreementGlenville Medical Concierge Care Step 1 of 6 - Agreement 16% I have engaged Glenville Medical Associates, PC dba Glenville Medical Concierge Care (GMCC) and its physicians Judith F. Shea, MD, Jeffrey S. Puglisi, MD, Ralph J. Cipriani, MD, Erika S. Krauss, DO and Cerrah L. Mendelsohn, MD to provide non-covered primary care services and other amenities and benefits to me/us for a period of one year beginning on December 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 December 9, 2024, as well as every 1-year period after that. $4,400/year = Individual (age 31 and over as of date of enrollment) $8,400/year = Adult Couple (age 31 and over as of date of enrollment) $2,250/year = Individual (ages 18-30 as of date of enrollment) Individuals (age 31 and over as of date of enrollment)0123456Individuals (ages 18-30 as of date of enrollment)01234567This field is hidden when viewing the formTotal members(will be hidden, for logic only)31 and over Price: $0.00 Couple Discount Price: $0.00 18 - 30 Price: $0.00 Total $0.00 I have read and understand this Agreement as well as the “Highlights & Details” and “Frequently Asked Questions (FAQs)” materials provided to me by GMCC. I understand that this Agreement can be terminated upon 30 days written notice. If I terminate, I may receive a pro-rated refund, to be determined by the practice on a case-by-case basis. However, if the Comprehensive Wellness Evaluation has been completed, no refund will be offered. If GMCC terminates, I will receive a refund of the prorated portion of the paid annual fee, based on the number of days that have elapsed in the Service Year. Such refund will be paid to me within 30 days after termination. This Agreement will automatically renew for subsequent Service Years under the same payment terms unless I notify GMCC otherwise within 30 days of next payment due. The Membership Agreement terms and annual fee amount(s) will apply to all such subsequent Service Years, unless GMCC and I agree otherwise, in writing. 1st Individual (age 31 and over): Dr. Cerrah L. Mendelsohn is my primary physician at GMCC.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 31 and over): Dr. Cerrah L. Mendelsohn is my primary physician at GMCC.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 31 and over): Dr. Cerrah L. Mendelsohn is my primary physician at GMCC.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 31 and over): Dr. Cerrah L. Mendelsohn is my primary physician at GMCC.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 31 and over): Dr. Cerrah L. Mendelsohn is my primary physician at GMCC.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 31 and over): Dr. Cerrah L. Mendelsohn is my primary physician at GMCC.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 Individual (age 18 - 30): Dr. Cerrah L. Mendelsohn is my primary physician at GMCC.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 18 - 30): Dr. Cerrah L. Mendelsohn is my primary physician at GMCC.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 18 - 30): Dr. Cerrah L. Mendelsohn is my primary physician at GMCC.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 18 - 30): Dr. Cerrah L. Mendelsohn is my primary physician at GMCC.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 18 - 30): Dr. Cerrah L. Mendelsohn is my primary physician at GMCC.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 18 - 30): Dr. Cerrah L. Mendelsohn is my primary physician at GMCC.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 Individual (age 18 - 30): Dr. Cerrah L. Mendelsohn is my primary physician at GMCC.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 months intervals, continually while this Agreement remains in effect. I understand one-half of the annual fee will be charged upon receipt of this form and the balance will be charged automatically at 6-month intervals, continually while this Agreement remains in effect.I understand one-quarter of the annual fee will be charged upon receipt of this form and the balance will be charged automatically at 3-month intervals, continually 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:This field is hidden when viewing the formPayment Methodcredit cardACHCredit Card DetailsCredit Card Type* Visa Master Card AMEX Discover Card Number*Card Number*Expiration MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberExpiration Year2023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050Security 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 GMCC 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 GMCC 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 AdvertisingOther Δ
