1303 Homestead Road N #102 Lehigh Acres, FL 33936

Tel: 239-303-2700 info@lehighmd.com

“The Affordable Medical Plan”

Welcome your Enrollment to The Affordable Medical Plan.

This is an alternative medical plan available for individual not legible to obtain health coverage under the health care reform Obama Care due to their low income or immigration status. This medical plan is exclusive for patients established for primary care in The Medical Centre of Lehigh Acres. This is not a Health Insurance, and does not provide coverage for services rendered outside of the premises of The Medical Centre of Lehigh Acres other than Radiology & Imaging services. This plan does not provide coverage for visits to Emergency room, Hospital or Urgent Care Facility. This plan will not provide coverage for any services out of the scope of our practice; this plan is limited to primary care or general medicine practice. This plan will not provide any health coverage for services if you are referred to a specialist for continue care or to any other medical facility to continue care. This plan is not affiliated to any insurance company, health care broker, or any other health care facility. The plan administrator will assist the member to obtain discounted fees For services by specialist physicians, these discounted fees are subject to the Rates for fees for services available to the self pay patients by the specialist physicians. This plan is extended for services rendered only by the physicians and professional staff of The Medical Centre of Leigh Acres.

Our Mission Value Services & Quality Health Care working together

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The Affordable Medical Plan

Membership Application

Our policy is to provide equal membership opportunity to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, ancestry, physical or mental disability, or veteran status.

Date _____________________ Membership Effective Date:________________________

Last name ________________________ First name ________________ Middle name________

Street Address _________________________________________________________________

City _____________________ State _______ ZIP __________________

Home Telephone ___________________________ Cell Telephone_______________________

E-mail: _______________________________________________________________________

€ Employed: If you are currently employed, tell us about your employer. Unemployed

Employer:___________________________________ Telephone:________________________

Name of a relative not living with you:

_____________________________________________________Telephone:____________________

3 Member Name:_________________________________________DOB:______________________

Membership Coverage with payment Selection

Select one initial payment for the membership and review the plan coverage according to the payment selection.

Upon made the initial payment selected the membership will be renew in a monthly basis at $65.00 each. Member may request to cancel membership at any time.

This is not a contract and membership is renew in a monthly basis upon payment is received.

□ $65.00 First month payment. □ Credit □ Check □ Cash

These are the covered benefits with 1 month membership payment.

□ 1.Unlimited Office Visits Co payment $20.00

Service Conditions with the benefits available in the plan 1. The  office  visits  are  unlimited  during  the  first  month  payment.  The  visits  are  limited  to  

primary  care  services  and  prescriptions  refills.  These  visits  do  not  include  wellness  or  physical  exam.    

Member Signature: Date:

□ $195.00 Three month pre-payment. □ Credit □ Check □ Cash

These are the covered benefits with 3 months membership payment. 1.□ Unlimited Office Visits including wellness &physical exams. Co payment $20.00 2.□ Woman Health Annual Visit Co payment $80.00 3.□ Minor Procedures/Surgery Visit Co payment $80.00 4.□ Laboratory Analysis Services Co payment $30.00 5.□ Diagnostic: EKG – Audiogram – Spirometry Co payment $15.00

Services Conditions with the benefits available in the plan 1. Physical exam does not include any vaccines or testing requirements. 2. Woman Health Annual Exam is limited to services render by primary care physician. 3. Minor procedures and minor surgery will be perform with the doctor approval for the procedure and these are limited to mole removal, drainage, Cerumen removal, Nebulizer treatments, nails removal, stitches, stitch removal or any other doctor required. 4. Laboratory analysis services are subject to doctor’s order. Under the plan we will Only accept orders by our staff physicians. 5. Diagnostic Testing EKG, audiogram or Spirometry with our doctor’s order only. Member signature: Date:

4 Member Name:_________________________________________DOB:______________________

□ $325.00 Five months pre-payment. □ Credit □ Check □ Cash

These are the covered benefits with 5 months membership payment. 1.□ Unlimited Office Visits including wellness &physical exams. Co payment $20.00 2.□ Woman Health Annual Visit Co payment $80.00 3.□ Minor Procedures/Surgery Visit Co payment $80.00 4.□ Laboratory Analysis Services Co payment $30.00 5.□ Diagnostic: EKG – Audiogram – Spirometry Co payment $15.00

Preferred Diagnostic Services: Cleveland Radiology Center A.□ Radiology Services Co payment $50.00 B. □ Imaging Mammogram visit Co payment $100.00 C.□ CT- Scan & MRI visit Co payment $130.00 D.□ Ultrasound visit Co payment $80.00

Services Conditions with the benefits available in the plan

1. Physical exam does not include any vaccines or testing requirements. 2. Woman Health Annual Exam is limited to services render by primary care physician. 3. Minor procedures and minor surgery will be perform with the doctor approval for the procedure and these are limited to mole removal, drainage, Cerumen removal, Nebulizer treatments, nails removal, stitches, stitch removal or any other doctor required. 4. Laboratory analysis services are subject to doctor’s order. Under the plan we will Only accept orders by our staff physicians. 5. Diagnostic Testing EKG, audiogram or Spirometry with our doctor’s order only. A. Radiology Services are available with orders made by our primary physician only. We will not accept orders made by physicians other than our staff. (Co-payment is good for One radiology series. Cannot be combined with multiple orders. A co payment will be Required for each series. B. Annual Screening Routine Mammogram is covered. If a Diagnostic Mammogram is required The member will pay a double co payment for this service. C. CT-Scan & MRI is limited to orders made by our primary care physician. We will Not accept orders made by physicians other than our staff. (Co-payment is good for one Diagnostic service at a time, multiple diagnostic studies will require a copayment for each Order. D. Ultrasound Studies are limited to orders made by our primary physician only. We Will not accept orders made by physicians other than our staff. (Co-payment is good for one Ultrasound service at a time. Multiple ultrasound studies will require a copayment for each Order. Member signature: Date:

5 General Exclusions: The Affordable Medical Plan excludes the following services and members are subject to the standard rates as disclosed in our rate fees. Some of these services are not provided in our center unless insurance is available for service reimbursement.

• Pregnancy • Weight Loss • Laser therapy for smoking cessation, drugs & alcohol. • Psychiatry evaluation, or treatment • Disability benefits, evaluation or treatment • Motor Vehicle Accident, evaluation, or treatment • Slip & Fall, evaluation or treatment • Work related injury subject to workman’s compensation benefits • Specialty Evaluations, care or treatment

I certify that the facts set forth in this application for medical plan coverage are true and complete to the best of my knowledge. I understand that if false statements or misrepresentation on this application shall be considered sufficient cause for cancellation.

I understand this is an application for a Medical Plan for medical services rendered by the Physicians at The Medical Centre of Lehigh Acres. This is not insurance and will not provide any coverage outside of the premises of The Medical Centre of Lehigh Acres other than the services covered in the medical plan.

Coverage outside of the premises of The Medical Centre of Lehigh Acres is limited to Radiology and Imaging Center Services to the preferred diagnostic center authorized by The Medical Centre of Lehigh Acres, Inc. I understand if I am in default for a monthly payment and regardless of my medical condition I will not be able to obtain medical services for me as an individual and my membership will be cancel unless all due payments are paid at the time of service.

Member Signature_______________________________________________ Date _________________

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APPENDIX A CREDIT CARD AUTHORIZATION FORM

The Medical Centre of Lehigh Acres accepts Master Card, Visa, Discover, and American Express cards for payment of patient medical services including The Affordable Medical Plan membership fees and the following information is required. The credit card will be charged within seven business days of receipt of this form executed by the patient or member. Site Name: The Medical Centre of Lehigh Acres, Inc In payment of: Monthly Membership_______________ Medical Service________________ Member/ Patient Name ___________________________________________________________________________ Name on the Credit Card:_________________________________________________________ Telephone: ___________________________________________________ Billing address:_______________________________________________________________ City:________________________ State:___________________ Zip Code:_______________ Credit Card Number:_____________-_____________-_______________-_____________ Exp Date: _______/_________ CVS #_____________ (3 digits on the back) Month Year I authorize The Medical Centre of Lehigh Acres to charge the credit card listed above for the Recurrent Monthly Charge: $65.00 . (Card will be charge on/ after the 1st of each month) The recurrent monthly charge is available for members in the Value Plan Membership Medical Plan only. CARD HOLDER: Signature:______________________________________________________________ Printed Name:___________________________________________________Date:_________________

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Appendix B

Terms & Conditions. 1. Member is defined as primary member,. 2. The Medical Centre of Lehigh Acres is not a licensed insurer, health maintenance organization, or

other underwriter of health care services. 3. Our discounts prices contained herein may not be used in conjunction with any other discount

plan or program. All listed or quoted prices are current prices from our list of services which is subject to changes without notices.

4. This is a Medical Plan that provides medical services limited to the scope of our practice. Medical services are subject to change without notice. This is a pre paid medical membership program only, not insurance, and may be discontinued or modified at anytime.

5. Savings are based upon the provider's Medicare fees. 6. Our Medical Providers are licensed to provide medical care and services to patients enrolled in

the medical plan and established for primary care in The Medical Centre of Lehigh Acres. 7. Refund Policy and 30-day Money Back Guarantee: If you cancel for any reason within 30 days

after the effective date, you will receive a full refund of the paid membership fees, excluding a charge of the one-time application fee $50.00. The refund is providing that the member did not received medical services in our facility during the membership period.

8. Notice: This contract is not covered by any life and health guarantee association. 9. This is not insurance nor is it intended to replace insurance.   Disclosures This plan is NOT insurance. The plan member is obligated to pay a monthly membership fee to obtain the services as it is outlined in this membership package. Our scope of practice is limited to primary care medical services. This medical plan program contains a 30 day cancellation period. Member shall receive a full refund of membership fees, excluding registration fee $50.00 if membership is cancelled within the first 30 days after the effective date. A refund of all fees will be issued if membership is cancelled within the first 30 days. The Affordable Medical plan is not insurance coverage. 10. The membership fee is due on the 1st of each month. The member will receive via

US mail a late notice with intent to cancel within 15th days if the payment is not rendered by the 15th day of the month. Payments made after the 15th of each month is subject to a late charge fee of $25.00. Returned checks or ACH transactions are subject to an additional fee of $25.00

11. Medical plan coverage is available with active membership and without default in payment. If the membership is cancel for non-payment the member will not be legible to join the plan or receive the benefits of the plan until all payments for services rendered are made. Payments made after 60 days will require a new membership.  

I acknowledge reviewing the terms and conditions and the disclosure clauses for The Affordable Medical Plan Membership.

Member Signature:____________________________________________ Date:________________