Membership and Account Authorization Form
smartERcoverage™
1. PROGRAM. smartERcoverage™ is an annual membership program for individuals over the age of 2 that provides access to local medical services at discounted rates. The smartERcoverage™ program provides up to ten visits per Members to smartERclinix™ locations for primary or immediate care during a year period. In addition, Members will receive a 50% discount off billed charges for the following: visits over the ten included visits; prescription drugs that are part of the smartERclinix™ formulary; in-house lab tests; diagnostic testing (including X-Ray, MRI, CT, Ultrasound and Digital Mammography); and crutches, braces and splints that are regularly stocked by smartERclinix™. Medical services provided by any other party or at any other location, including hospital emergency rooms, physician offices, and pharmacies, are not included under the smartERcoverage™ program. Medical Services will be provided by smartERclinix™’s professional staff. Services may be provided at another location by a smartERclinix™ affiliated clinician or physician.
2. COSTS. The cost to participate in the smartERcoverage™ program is $396.00 for the year, payable at $33.00 per month. Members in the program will not be charged deductibles or co-insurance.
3. TERM. The term for Membership in the smartERcoverage™ program is one (1) year, and shall commence on the date this agreement is signed. Membership may be renewed on an annual basis. smartERcoverage™ retains the right to refuse to renew Membership in the program. If a Member desires to cancel Membership in the smartERcoverage™ program, Member may choose to pay the remaining monthly fees in one lump sum or continue the monthly payments until the end of the term.
4. NOT INSURANCE. The smartERcoverage™ program is a program designed to make primary and immediate care medical services provided at smartERclinix™ affordable. The program is not an insurance plan. This agreement does not create or should not be construed to create any relationship of insurer-insured or physician-patient. It does not provide any payment or reimbursement for amounts charged by any other medical provider. Program visits are not transferable and unused annual visits do not roll over to the following year.
5. MEMBERSHIP; AUTHORIZATION TO DEBIT ACCOUNT. Member has read and understands the above terms describing the smartERcoverage™ program, and desires to participate in the smartERcoverage™ program. Member authorizes smartERcoverage™ to charge his or her credit card, debit card or PayPal account for the monthly payment of $33.00 during the term of this agreement. Member understands that this charge will be made on the monthly anniversary of the date the Member signed the agreement. Further, Member agrees to maintain sufficient funds or credit in the PayPal account/debit card/credit card to permit the monthly charge described above. smartERcoverage™ may cancel or suspend Member’s participation in the program if sufficient funds or credit are not available to permit the automatic payment. The full amount of the program charge, $396.00, is payable by Member regardless of any non-use by Member of smartERclinix™ services and regardless of any termination of this contract. Members who elect to pay the full annual program charge in advance by cash, check or debit/card are entitled to a $10.00 discount making the total annual program fee $386.00.