About | Synergy Medical Group

VOLUNTARY MEMBERSHIP ENROLLMENT ACKNOWLEDGMENT

Name(Required)

First Last

Synergy Premier Access is an optional membership program. Please review and acknowledge the statements below.

Date of Birth(Required)

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Please check each box to acknowledge(Required)

I understand enrollment in Synergy Premier Access is completely voluntary.

I understand I am not required to enroll to receive medical care from the practice.

I understand I may continue to receive medically necessary healthcare services even if I do not enroll.

I understand Synergy Premier Access is not health insurance and does not replace insurance.

I understand the practice may bill my insurance/Medicare for covered medical services when applicable.

I understand the membership fee is for enhanced access, administrative support, and care coordination services not reimbursable by insurance/Medicare.

I have had the opportunity to ask questions and my questions were answered.

I understand no guarantees can be made regarding treatment outcomes.

Signature(Required)

Date(Required)

Non-Insurance Disclosure & Financial Understanding

The membership fee is paid only for enhanced access, administrative support, and care coordination services. It is not insurance and does not pay for covered medical services.

Name(Required)

First Last

Date of Birth(Required)

Acknowledge each statement”(Required)

I understand Synergy Premier Access membership is NOT health insurance.

I understand the membership fee does not pay for medical diagnosis, treatment, office visits, procedures, testing, or management of medical conditions.

I understand the practice will bill insurance/Medicare/third-party payors for covered medical services when appropriate.

I understand I am responsible for deductibles, copayments, coinsurance, and non-covered services per my insurance plan.

I understand I am not required to enroll in Synergy Premier Access to receive medical care from the practice.

I understand choosing not to enroll will not affect my ability to receive medically necessary healthcare services from the practice.

I understand the membership fee is for enhanced access, communication, administrative services, and care coordination that are not reimbursable by insurance/Medicare.

Medicare Beneficiaries

Are you a Medicare Beneficiaries?(Required)

Yes

Medicare Beneficiaries(Required)

If I am a Medicare beneficiary, I understand I may receive all Medicare-covered services from the practice whether or not I enroll.

I understand no Medicare-covered service is conditioned upon payment of a membership fee.

Signature(Required)

Date of Signature(Required)

Recurring Payment Authorization

By completing this form, you authorize Synergy Premier Access to charge the membership fee on a recurring basis.

Name(Required)

First Last

Date of Birth(Required)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Card Type(Required)

Visa

Master Card

Discover

American Express

Last 4 Digits of Card(Required)

Expiration (MM/YY)(Required)

Monthly Membership Fee

$150/Monthly

Authorization(Required)

I authorize Synergy Premier Access to automatically charge my card on or about the first business day of each month for the membership fee.

“I understand”(Required)

Charges will occur monthly on a recurring basis.

I may update my payment method at any time.

I understand cancellation requires notice per the Membership Agreement.

This authorization remains in effect until I cancel in writing.

Signature (Cardholder)(Required)

Date(Required)

Oak Concierge Medicine to Synergy Premier Access Consent Forms

VOLUNTARY MEMBERSHIP ENROLLMENT ACKNOWLEDGMENT

Non-Insurance Disclosure & Financial Understanding

Medicare Beneficiaries

Recurring Payment Authorization