MembershipGuyer Wellness Group Membership Program Name First Last Email PhoneThis program is a 12-month plan that gives me access to me primary, anti-aging, functional medicine, and clinical wellness care plus rolls in all of my deductibles and copays for only $297 a month if I have insurance. If I do not have insurance, cash pay would be $350 a month. As a member, I understand that I receive VIP access to care, testing, treatment and services. I will read this document in full as it outlines the exact details of this program and what is included. As I read each section, should I have any questions, I know to ask a team member so that I can have all of the information necessary to make an informed decision to become a member of this practice. Today 86% of disease is chronic and lifestyle driven. Understanding this, we take a different approach than most, ensuring that YOU are at the center of care. Unlike other doctors, our team of certified physicians, nurses, and coaches are also trained in functional and integrative medicine. This means we are trained in how to use nutrition, lifestyle change, and cutting-edge testing to help you not only reverse and prevent disease, but also thrive in today’s fast paced world.What is the 12 Month Membership? It is our answer to affordable care. We believe that every patient should have access to his or her doctor. With high deductibles, co-pays, and limited coverage, the patient is the one that suffers. As a member of our concierge practice, you will have peace of mind knowing that your exact out of pocket expense is only $297 with insurance each month/$350 cash pay with unlimited access to the care you need in our practice. This one fee includes all deductibles, copays and care for one price.We take a team approach and our members see more than just one provider during their health journey with us! Membership offers patients with unprecedented access to our providers, and the best integrative primary care available. Plus, all members are guaranteed time with their providers. This personalized approach ensures that we understand your health goals and work in a collaborative manner.Is this covered by my HSA or FSA? You can use FSA/HSA for your membership. Each plan is different, so you will need to contact yours to find out the exact approval process needed to cover your care.How am I billed? You will be set up on an automatic debit program. This ensures that each month, on the same day, your credit, debit, or HSA card will be charged for the $297 insurance/$350 cash pay amount. This recurring charge is for 12 months. At the end of 12 months, you will have the opportunity to cancel with no cancellation fees or automatically renew staying locked in at the $297/350 rate even when rates for new patients go up.What if my card is updated, lost or stolen? We understand that cards expire, new cards get issued, and accounts change. If this happens with the payment type you have with us on file, to avoid a 15% administrative processing fee for late payments, we request that you immediately notify us with your updated payment type so we can help to keep your membership and account active and in good standing.Initial*What’s included in my membership? ● 1 Annual Comprehensive appointment with our Nurse Practitioner, 30 minutes, billed to insurance but no cost to the patient. If patient does not have insurance, the $350 fee will cover your expenses. Fee includes all deductibles, copays, and care for one price. ● No fee on Injections (Savings: $720) ● 1 Free B12 Injection weekly (Savings: $1,440) ● 1 Free Myer’s Cocktail IV, once monthly (Savings: $1,188) ● No copay on follow up appointments ● 10 % off of all supplement purchases ● 10% off of Aesthetics ● Advance notice of new treatments and therapies ● Free labs for Second Pellet Session ($150-250 value) ● Braincore NeuroFeedback/Mapping (Billed to Insurance) ($300 value) (Savings: Around $16,200)When does my membership start? Membership begins the day you register in office. What is NOT included in my membership fee: The following are not included in your membership fee: ● Supplements members choose to purchase through our platform or other sources ● Hormones or prescriptions advised by your Live Longer Medical team ● The cost of laboratory tests (If you require testing, we offer affordable lab solutions) ● Healthcare services other than those specified above, whether provided by our group or others. Services provided other than by Live Longer Medical, such as emergency and specialized care, will be billed to you or your insurance plan by those providers. ● Non-medical services recommended by our group but provided by others, such as acupuncture and personal training.Scheduling and Cancellation of Appointments: ● We ask for your full respect to your time and the time of our team so that you can gain the optimal support you deserve. To ensure this, we have a firm cancellation policy requesting a 24-hour cancellation notice for all appointments with Kristen Laurella ARNP, any health coach, or team member. Canceling within less than 24-hours will result in a $75 charge to the credit card on file.Initial*● No-shows: If you do not show up to an in office or video/ telemedicine appointment without notifying the specific person you have an appointment with either via email or by changing the appointment with the office, you will be charged $75 to the card on file.Initial*We are not an insurance plan: We advise all members to maintain a separate health insurance plan of their choosing. You should also note that the Affordable Care Act includes a general requirement that all U.S. citizens purchase health insurance. Our membership does not meet this requirement.We bill insurance: Due to our guarantee of time with our patients, this is considered added value services many of which insurance does not cover. We will however, bill your insurance on your behalf for the care that is covered. All billed services allowed will apply towards your deductible at no additional fee to you.We are not an emergency or urgent care: Our availability is during normal working hours Monday-Friday and your availability to reach us or access our services at any given time may be limited. If you require urgent care you should immediately call 911 or contact an emergency care services are not covered by your Live Longer Medical membership.Lab Testing: ● Some blood tests we offer as part of our functional medicine testing program may be covered by insurance and in these cases, we will work with you to access these tests through your insured provider. ● If additional advanced diagnostic testing is needed, the specific tests ordered will be personalized to you based on your initial evaluation with our team and may include blood, saliva, urine, food or stool testing. ● We will make every effort to make you fully aware of any additional lab fees that may be incurred and to give you the opportunity to choose which lab tests you feel comfortable paying for. ● You are under no obligation to purchase any specialty testing. ● At home test kits: If a lab test kit is mailed to you by Live Longer Medical, you will be charged the day the kit is mailed. This is not included in your membership fee. Please note, if you have insurance, certain tests are covered and will be billed to your insurance, saving you any out of pocket expenses.We are not specialists: If you need to see a surgeon, OB GYN, or a cardiologist, for example, you will be referred appropriately. The costs associated with the services provided by specialists or any other health care provider outside of Live Longer Medical are not covered by your membership.Non-Transferrable: Your membership may not be shared, assigned or transferred to anyone else, even if you are not using it. We do offer employers the opportunity to provide our services to their employees on a discounted group basis. For more information on this, please contact us.What if I change my mind? We strive to deliver the highest quality of health coaching, care and service so you can fully optimize your health and wellbeing. We do understand that sometimes situations change, and if for any reason you find that you need to cancel your membership, we will honor your request to cancel minus a $297/350 registration fee. We only require a 30-day notice. Initial*Temporary interruptions in the availability of or access to Live Longer Medical services or interruptions due to circumstances outside of our control will not create a right to cancel your membership nor request a refund/credit.***I acknowledge that the terms and conditions of the Live Longer Membership Program have been reviewed with me and I understand and agree to all terms.Print Name*Date* Date Format: MM slash DD slash YYYY Signature*CommentsThis field is for validation purposes and should be left unchanged.