Keith T. Chumley, M.D., PC

I have engaged Keith T. Chumley Advisors, M.D., P.C. (Company) and its physician Keith T. Chumley, MD, to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning December 11, 2024. I understand that this Agreement will renew automatically following the end of each one-year period unless I provide the Company with a written notice of non-renewal at least 30 days before the end of a Service Year. I further understand that I will be required to pay a yearly membership fee at the start of each renewal term for these non-covered services, amenities, and benefits. As used in this Agreement, the term “Service Year” refers to the one-year period beginning on the date above, as well as every one-year renewal period thereafter.

$2,500/year = Individual
$1,250/year = Each Dependent when Parent is Enrolled (ages of 13 up to 26)

Individuals (26 and over)

Dependents (between the ages of 13 and 26)

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Total members

(will be hidden, for logic only)

Individuals (26 and over)

Price: $0.00

Dependents (13 – 26)

Price: $0.00

Total

This Agreement is for non-covered, non-clinical amenities and benefits as described in the Highlights & Details document. I have read and understand this Agreement as well as the Highlights & Details and Frequently Asked Questions 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 may 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 the Company 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 Company otherwise (or the Company notifies me) within 30 days prior to the next payment due date.

1st Individual (26 and over)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number(Required)

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email(Required)

2nd Individual (26 and over)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email(Required)

3rd Individual (26 and over)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email(Required)

Payment Schedule(Required)

I will pay annually

I will pay semianually

I will pay quarterly

I understand that 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 while this Agreement remains in effect.

I understand that one-half of the full annual fee will be charged upon receipt of this form and and one-half will be charged automatically at six-month intervals, continually while this Agreement remains in effect.

I understand that one-quarter of the full annual fee will be charged upon receipt of this form and and one-quarter will be charged automatically at three-month intervals, continually while this Agreement remains in effect.

Your ANNUAL Payment:

This is the amount that will be charged to your card 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 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:

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Payment Method

Credit Card Details

Your card will be charged by Keith T. Chumley Advisors, M.D., P.C.

Credit Card Type(Required)

Visa

MasterCard

AMEX

Discover

Card Number(Required)

Expiration Month

Expiration Year

Security Code(Required)

Cardholder Name(Required)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Daytime Phone Number(Required)

Consent(Required)

I authorize Keith T. Chumley Advisors, M.D., P.C. to automatically charge my credit card the amount(s) indicated on this form.

ACH Option

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Daytime Phone Number(Required)

Bank Name(Required)

Account Type

Routing Number(Required)

Please Confirm Your Routing Number(Required)

Account Number(Required)

Please Confirm Your Account Number(Required)

Consent(Required)

I authorize Keith T. Chumley Advisors, M.D., P.C. to automatically pull from my bank account the amount(s) indicated on this form.

Digital Signature(Required)

Please type your initials to confirm this agreement.

Is the home address different from billing address(Required)

Yes

No

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

How did you hear about our practice?(Required)

Please elaborate(Required)

Membership Agreement