Patient(s) identified below would like to participate in the mdPersonal ^TM membership offered by Dr. Neil F. Neimark. Patient(s) and Dr. Neimark acknowledge and agree to the following terms and conditions in connection with participation in the Practice.

PRACTICE COMMITMENTS

Dr. Neimark agrees that the Practice will maintain only a limited number of patients in order to assure that Patient(s) will have timely and convenient access to Dr. Neimark, who will be accessible 24/7 as events and circumstances allow.

EXCLUSIVE MEDICAL PRACTICE SERVICES FOR MEMBER PATIENTS

• 24 hours a day, 7 days a week direct telephone and email access to Dr. Neimark.
• Same day or next day appointments with no waiting or minimal waiting times as circumstances allow.
• On time and unhurried appointments for as long as necessary to cover your presenting medical problems.
• Annual Comprehensive Wellness Examination at no additional cost to Patient(s) for in-house services.
• House calls for you and your family when you are too ill or unable to make it to the office.
• In-office lab specimen collection by office staff so Patient does not have to visit and wait at a laboratory.
• Medical concierge service to coordinate Patient’s complete healthcare needs, including prescription refills, scheduling of appointments for specialty care, laboratory and x-ray needs.
• Detailed coordination of specialty care, testing and accompaniment to specialists when appropriate.
• A focus on wellness through the promotion of preventive medicine and the early detection of disease.

PATIENT COMMITMENTS

• To participate in the Practice, Patient(s) will be required to pay an Annual Fee according to the following Fee Schedule:

Single Individual: $1800
Couples Package: $3400
Family of 3 Package (2 adults, 1 child): $3600
Family of 4 Package (2 adults, 2 children): $3800
Single Parent Package (1 adult, 1 child): $1800
Each additional child: $360

• The Annual Fee is for a 12 month period (“Term”)
• The Annual Fee is due on the effective date of this Agreement and on or before each anniversary thereafter as a condition for continuing as a Patient of the Practice.
• The Annual Fee is for services, including the Annual Comprehensive Wellness Examination, that are not considered covered benefits by insurance plans or Medicare. If any of the listed services are considered covered benefits, then the Annual Fee is for the remaining list of services.
• Financial discounts may be given for certain individuals based on financial need and/or individual considerations.

PATIENT ACKNOWLEDGMENTS

Patient acknowledges that the Practice is a unique program with certain specific limitations, as follows:

• The Annual Comprehensive Wellness Examination is limited to those services and procedures performed by Dr. Neimark in his medical office as part of a comprehensive annual physical examination. The Annual Comprehensive Wellness Examination includes collection and review of medical history, physical examination, stool examination for blood, EKG, spirometry, urinalysis, blood collection for the laboratory and a follow-up discussion of the results along with a plan to improve health. The Annual Comprehensive Wellness Examination will be performed by Dr. Neimark without any additional out-of-pocket expenses by Patient(s) for the services that Dr. Neimark can perform in his office. Services that are not covered by the Annual Fee include testing at outside facilities such as blood tests, x-rays, mammograms, colonoscopy, heart stress tests, etc.
• The patient has financial responsibility to pay for services that are provided at regular office visits that are not part of the Annual Comprehensive Wellness Examination. The Practice will bill Patient’s insurance for services, but the financial responsibility for full payment is that of the Patient(s).
• In the even that Dr. Neimark is unavailable, call coverage will be provided by another physician selected and overseen by Dr. Neimark.
• This Agreement shall automatically expire at the end of the existing Term unless Patient renews the Agreement and pays the Annual Fee for the next Term. Upon expiration or termination of this Agreement, Practice will transfer Patient(s) medical records and continuing care to any physician requested by Patient by written notice.

Total Annual Fee: __________ (Please refer to the membership categories on page 1 of this form)

Method of Payment: ( ) Visa ( ) MasterCard ( )American Express ( ) Check: Check Number: __________

Credit Card Account Number: ______________________

Expiration Month:_______ Expiration Year ________

PAYMENT: 50% of the Annual Membership Fee is due upon signature. You may pay off the remainder by selecting one of the options below:
( ) Semi-Annually (Includes one additional payment 6 months from now. $15 service fee applies)
( ) Quarterly (Includes three additional payments in 3, 6 and 9 months from now. $15 service fee each payment)
( ) Monthly (Includes six additional payments in 1,2,3,4,5 and 6 months from now. $15 service fee each payment)
( ) I would like to pay my entire fee in one simple payment.

NOTICE OF ACCEPTANCE:

Dr. Neimark acknowledges receipt of this agreement and application to become Patient(s) of Dr. Neimark’s Concierge Medical Practice. This agreement is effective from _______________________to _____________________
________________________________________
Neil F. Neimark, M.D.

Mail completed to: Neil F. Neimark, M.D. 4980 Barranca Pkwy Ste 207, Irvine, CA 92604