Membership Agreement

I agree that I

have engaged Next Generation Pediatrics, LLC (Next Generation) to provide concierge pediatric primary care membership and medical services to the individual listed below (Member) for a period of one year beginning on

(Start Date).

Member Name:

Member Date of Birth:

Term

This Membership Agreement is for one year and shall automatically renew every year on the Start Date until you notify Next Generation that you wish to cancel. As used in this Membership Agreement, the term “Service Year” refers to the one-year period beginning on the Start Date for the Member listed above as well as every twelve (12) month period automatically renewed, to the extent the Member Agreement has not been cancelled. The Start Date shall be (i) in the case of a newborn, the day of birth or (ii) in the case of an adopted or similar child, the day the family notifies Next Generation they desire to include the child as a Member of Next Generation. Should this Membership Agreement be cancelled for any reason, you shall be refunded the prorated amount of your membership fee.

Annual Membership Fee

In exchange for membership, you agree to pay Next Generation an annual membership fee of $2500 per Member per Service year (Annual Membership Fee). You acknowledge and understand Annual Membership Fee is for membership access to Next Generation and does not include fees for individual medical services (Medical Service) provided by Next Generation and you will be charged individual fees for Medical Services including but not limited to well visits, sick visits, hospital monitoring services, certain laboratory tests, vaccines and shots. You understand the Annual Membership Fee for access to Next Generation will be charged regardless of how many times the Member uses Next Generation.

Non-Participation in Insurance Plans

You acknowledge that Next Generation does not participate with nor accept any insurance coverage and that you will be responsible for the Annual Membership Fee and any Medical Service charges. Next Generation may refer the Member to other types of providers (e.g. clinical labs, hospitals, specialists) which may or may not be covered by insurance. You should contact your insurance company to determine if you will be reimbursed for any services provided by Next Generation or any referred provider. Next Generation makes no claims and shall not be held liable for any advice given regarding insurance and insurance reimbursement. For your convenience, we use current insurance coding for Medical Services and can provide you with coded, itemized bills.

Medical Services

You acknowledge that Next Generation provides primary care services under which its providers are licensed and trained to perform, including but not limited to, well visits, sick visits hospital inpatient monitoring services and certain ancillary services (e.g. rapid strep test, flu shot). You understand that comprehensive medical care may require medical care beyond primary care and acknowledge that Next Generation makes no representations and is not liable for any such care. Next Generation is not an insurance plan or a substitution for health insurance and does not cover hospitalization or any other services not provided by Next Generation. Next Generation recommends that the Member retain health insurance or other such similar plans.

Payment

You authorize Next Generation to charge you in accordance with Appendix A. You acknowledge and understand that Medical Services charges are due at the time of service.

Communications

Next Generation uses numerous types of electronic communications and we work to ensure that all communications are confidential and secure. However, you understand and agree that such electronic communications are not guaranteed to be secure or confidential. By providing your phone number, email address and other contact information below, you accept these methods of communication. By signing the Email Communications Authorization below in Appendix B, you authorize Next Generation to communicate with you using email communications. Although Next Generation makes every effort to respond immediately to Member communications, we do not accept any loss or liability due to any technical failures.

Miscellaneous

Amendment. This Membership Agreement cannot be amended without the advanced written consent of both parties.
Invalidity. You agree to pay for any and all services rendered by Next Generation if this Membership Agreement is held invalid for any reason.
Assignment and Transfer. This Membership Agreement, or any of the rights under it, may not be assigned or transferred by the Member or the Member’s representative.
Relationship of Parties. You agree that Next Generation is an independent contractor.
Governing Law. This Membership Agreement shall be governed by the laws of the State of Connecticut.

Signature:

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Printed Name:

Date:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone (primary):

Email Address (primary):

Phone (secondary):

Email Address (secondary):

Payment Agreement

I hereby authorize Next Generation Pediatrics, LLC to charge my credit card in full on the first day of the Service Year in an amount equal to the Annual Membership Fee. For families with multiple Membership Agreements, one Payment Agreement shall be valid for all Annual Membership Fees under each individual Membership Agreement.

MasterCard
Visa
American Express

Credit Card Number:

CVC Code:

Expiration Date (Month):

Expiration Date (Year):

Billing Address:

Address Line 1

City

State

Zip Code

Card Holder Name:

Card Holder Signature:

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I acknowledge if I terminate the Membership Agreement, Next Generation Pediatrics, LLC will refund the Annual Membership Fee to a prorated amount.

This Membership Agreement will be automatically renewed each Service Year and the Annual Membership Fee will be automatically charged on each Member’s Start Date. The terms of this Payment Agreement will apply to all such subsequent Service Years, unless Next Generation Pediatrics, LLC and I agree otherwise in writing.

Signature:

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Printed Name:

Date:

Email Communications Consent

To provide the level of availability we offer at Next Generation Pediatrics, LLC, we utilize numerous forms of communication including, but not limited to email communication and we encrypt our outgoing email to the best of our ability. By entering into the Member Agreement you agree that Next Generation Pediatrics, LLC may send protected health information (which may include diagnosis and treatment information), payment information and other information through the Internet to an email address you designate. You acknowledge that any electronic communications and protected health information received by you can no longer be protected by Next Generation and you are responsible for all electronic communications in your possession.

Member’s Name:

Member’s Date of Birth:

Parent(s)/Guardian(s) Name:

Date:

Signature:

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