Team Doctors Preferred Access Membership Packet

Immediate Access | Elite Physicians | Peace of Mind

Membership Packet

www.theteamdoctors.com | 1.888.424.0102 | Immediate Access. Elite Physicians. Peace of Mind. 2

It is our preferred access offering, along with the elite caliber of physicians in our network, that provide you and your family the ultimate peace of mind concerning your medical care. There are many reasons our members have decided to choose Team Doctors Preferred Access, but the most common denominator is the desire to have the best doctors in the country caring for them and their family. Team Doctors is your total medical resource, not only on a local basis, but in major cities all across the U.S.

TIME IS YOUR MOST VALUABLE RESOURCETime is your most valuable resource. When you join Team Doctors Preferred Access, you will no longer have to worry with the time consuming task of researching doctors, questioning if you chose the right one, then scheduling and waiting for appointments, only to arrive and fill out lengthy paperwork, culminating in hours spent at the doctor’s office.

As a member, you can routinely expect same or next business day appointments to our core team physicians in our network. Our members also enjoy “front-of-the-line” treatment, which means limited wait times, if any, upon your arrival and little or no paperwork.

TRUST AND CONFIDENCETeam Doctors Preferred Access is the most exclusive network of Physicians who manage the care of United States professional athletes of the MLB, NFL, NBA, NHL, in addition to the athletes of the Olympics, World Cup Soccer and the Super Bowl.

This network of distinguished physicians also provides access and medical care for celebrities and high profile corporate executives. Our Team Doctor physicians are personally networked to top specialists around the country and over the years have referred athletes for any medical condition around the clock. Now you can enjoy this once private network of physicians and experience the same level of access and expedited referrals.

Our members have the confidence in knowing that the owners & leadership teams of these professional sports’ franchises chose and trusted our physicians to oversee and direct all of the medical care for their most prized assets, the professional athletes.

Immediate Access. Elite Physicians. Peace of Mind

A Team Doctors Preferred Access membership is the most powerful medical access solution in existence.

Our physicians’ skill and expertise is unmatched. This skill combined with the reach of our network and expedited access makes the Team Doctors Preferred Access Membership unrivaled in the industry.


OUR HISTORY

Our network has developed over twenty years of the team physicians coordinating care on behalf of professional athletes and high profile individuals. After twenty years in working with one another, our physicians decided to formalize this peer network in order to make this unique, elite network of physicians and premier level of medical care available to the public with the same expedited level of access that professional athletes have.

Team Doctors Preferred Access was founded after contracting 28 core team doctors in major cities across the country and developing our premier medical access membership offerings. When the medical need arises, you can now feel comforted in knowing that as a member of Team Doctors, all it takes is one phone call to receive an expedited response for any health issue and have it be addressed by a network of the most highly acclaimed physicians in the country, whether at home or traveling abroad.

How our physicians were chosenThe Team Doctors all share one unified mark of distinction. They were hand chosen by the team owners of billion-dollar professional sports’ franchises to diagnose and care for their multi-million dollar athletes because of their demonstrated expertise, respect from their fellow colleagues, and reputations as premier physicians in their communities. Our physicians did not apply for their positions as the head doctors within these professional sports franchises.

There is no substituteThe Team Physicians’ core function for the teams they serve is to keep those athletes in the best health possible so they can perform at their highest levels. If that athlete has a medical problem, it is up to the team physicians to diagnose, treat, and refer (when need be) to the top specialist to bring those athletes and individuals back to optimum health, quickly.

The Team Doctors network is not an artificial network assembled and purchased by an outside concierge company where the physicians do not personally know each other. That is why when we say that you can’t replicate this network, you really can’t. There is only one physician network at this level in the world.

The most trusted & exclusive physician network in medical care

“We founded Team Doctors Preferred Access to offer a unique exclusive service to the medical access market. We have a national network of physicians who have

distinguished themselves by being selected to provide medical care for

celebrities and high profile athletes for many years. These high profile clients

have received exceptional medical services and they do so on an expedited

basis- no waiting for appointmentsor in waiting rooms.”

- Dr. Robert Gadlage, Chairman


As a member, you receive:

The Team Doctor Physician Access Line Membership card(s) for you and your family

members* Same or next business day appointments to

the core team physicians Expedited access to hundreds of renown

specialists Limited wait times in the waiting rooms Secure online storage of your medical

profile Personal Advocate to coordinate all of your

appointments and care Access to premier nutritionists and trainers Newsletter updates Partner exclusive offers Access to invitation only events

The Team Doctors Physician Access LineAs a member, you will receive a physician access line available 24/7/365 days out of the year. You may dial this number at any time and reach your advocate, who will promptly respond to your call. Please be advised that all of your appointments to physicians will be scheduled during regular office hours generally between 9am and 5pm Monday through Friday.

Membership CardUpon becoming a member, each member of your family will receive a membership card containing your physician access line on the back and your member ID number.

Each card contains instructions to dial 911 if you are impaired and then dial our physician access line on your behalf to let us know of your situation.

Same or Next Business Day Appointments to the Core Team PhysiciansAs a member you can also expect same or next business day appointments to our core team physicians locally or as you travel across the country. You may dial your advocate at any time, who will then schedule an expedited appointment for you at a doctor’s office. We recommend you utilize these physicians for your care. If you are located in a city in between one of the major cities of the team physicians, you will want to take the time to access these physicians in the major cities.

Benefits of Membership


Limited Wait Times in Waiting RoomsYou can expect expedited wait times at our core team physicians’ offices. Your advocate will have notified that office of your pending arrival ahead of time. If that physician is experiencing an emergency situation or complication at their office, your wait time may be longer than anticipated, otherwise you will receive front-of-the-line treatment.

When being referred outside of the core team physicians to our extended network of specialists, wait times in their offices may vary depending on the circumstances. The priority for you, as a member, at the specialists’ offices is to

expedite and reduce your wait time for the appointment and upon arrival for your appointment, since these appointments generally may require weeks, if not months to schedule.

Expedited Access to SpecialistsThere is no limit to your access to elite medical resources as a member. The core team physicians have established peer to peer relationships with a host of specialists’ networks. Our doctors may sometimes help assist in navigating you to physicians outside of the major cities, but they recommend you access the actual team physicians or specialists they have recommended. After all, this should be a major reason you are thinking about purchasing this membership.

Personal AdvocateAs a member, you will receive your own personal advocate to coordinate all of your access and care. Anytime you call into the Team Doctors physician access line, your advocate will promptly return your call 24/7/365. Your advocate is the liaison between you and the physician, and assist you every step of the way in navigating medical care.

Secure Online Storage of Your Medical ProfileUpon becoming a member, you will receive a secure link to fill out your online medical profile. Your information will be securely stored in an online medical database. Anytime you have an appointment, your advocate will forward your information to the doctor’s office ahead of time on your behalf.


Health and WellnessThe team physicians, besides being stand out physicians in their communities, are n o doubt some of the brightest in the areas of navigating wellness, nutrition and physical training resources based on your needs. They do so for professional sports teams at the highest levels; it is a tremendous resource at your fingertips.

Many of our members take advantage of their preferred access to premier specialists in the areas of nutrition and fitness through our

networks. Whether it is designing a personalized nutrition plan to help you maintain a healthy weight goal, attending an educational seminar on wellness, or consulting with a world class fitness trainer for an optimum exercise program, we are one phone call away to getting you started on the path to optimal health and wellness.

Newsletter UpdatesAll of our members will receive the Team Doctors Newsletter. We strive to keep our abreast of current events, information on medical advances, articles of interest, new partner announcements, updates on Team Doctors and invitations to events.

Partner Exclusive Offers & InvitationsIn a continual effort to bring you the best, Team Doctors will periodically partner with other eliteservice oriented organizations. Our members will receive exclusive offers to take advantage of partner discounts through our newsletters and updates. This may include the areas of travel, jet and car clubs, nutrition & wellness programs, concierge platforms, dining, local events and more. Members will also receive invitations to exclusive Team Doctors, Partners’ and charitable events around the country.

Additional Membership Benefits


The Call Process and What to ExpectYour physician access line is available 24/7 365 days out of the year. You may dial this number at any time and reach your advocate, who will promptly respond to your call.

Please be advised that all of your appointments to physicians will be scheduled during regular office hours generally between 9am and 5pm Monday through Friday. When you dial your Team Doctors Physician Access Line for appointments, a contact center representative will ask you if your call is

emergency related or if it is to speak with a representative about an appointment.

If it is an emergency, you will be instructed to hang up and dial 911 in the U.S. When able, if you have dialed 911 first, you will then dial your physician access line and notify us that you have dialed and connected with 911. We will help assist you when able, but please remember that WE ARE NOT AN EMERGENCY SERVICE. If it is not an emergency and you are calling for an appointment, the contact center representative will ask you for your location, best contact number you can be reached at, and description of your symptoms to give to your advocate.

Understanding the NetworkIt is important to understand that your access to elite medical resources as a member is limitless. There are different levels of physicians’ you will have access too:

The Team PhysiciansThese are the front line team physicians, the coreof the Team Doctors network. Most of thesephysicians are family or internal medicine practitioners. These doctors, in essence, are the “quarterbacks” of our network. Our core team physicians diagnose, treat, and refer when necessary to their networks of specialists.

Tier One SpecialistsWhen members need to be referred to a specialist, they are generally referred to one of these specialists on an expedited basis:

Cardiologists Gastroenterologists Orthopaedic Surgeons Ear, Nose, and Throat Specialists

How it Works


Tier Two SpecialistsBeyond this first tier of specialists are even more complex, specific specialists. The head team physicians combined with the tier one specialists can provide expedited access to all of the other top specialists covering virtually ANY medical need or concern. This includes access to literally hundreds of premier physicians inside the top medical centers and hospitals in the world-on a peer to peer basis on your behalf.

Your Health Insurance and MembershipYour membership is not a form of health insurance, although it has been called “assurance” by many of our members. Most of the physicians you will be directed to will accept all of the major health insurance carriers. Some of them may not take your insurance. In those instances where the team physician or specialist does not accept your insurance, you will be given the option to see those physicians out of network or be referred to another

physician who accepts your insurance. Your advocate will help you coordinate this with the physicians’ office.

ChildrenAlthough the Team Doctor Network is not specifically designed for children, we may be of assistance in directing our members to highly reputable physicians for care of their children. Children should be able to expect expedited appointments to specialists such as Pediatricians; however their wait times may vary because they are outside of the core team physicians.

Corporate MembershipWe offer premium level corporate memberships as well. Our corporate membership programs mirror the same level of benefits as our individual and family memberships and are customized with additional offerings. If you are interested in learning more about our corporate offerings for your executive team, employees or business please contact us for a corporate membership brochure.

Additional InformationPlease visit our website www.theteamdoctors.com for more information, including membertestimonials and doctor bios. You may email us at: [email protected] or call 1.888.424.0102. Please allow one business day for us to respond to your requests.

Again, thank you for your interest in membership. We look forward to the opportunity to provide you and your family with the ultimate peace of mind.


Is a Team Doctors Preferred Access Membership for you?

Good questions to ask yourself:

You value and appreciate the highest quality health care available You care about your family members having the highest quality health care available You or your family members have a need for expedited appointments and care You or your family members travel for business or pleasure You are willing to drive to a major city to see a Team Doctors Preferred Access Physician

This is just for access to the top doctors in major cities, not in between, because we have more control of the doctors in our network and they have all been “qualified and tested” by their experience and peers.

Membership Agreement Instructions

Complete the attached agreement and:

Fax to 888.424.0102 along with credit card authorization formOR Email to [email protected] along with credit card authorization formOR Mail along with check/credit card form to:

Team Doctors Preferred Access, LLC3855 Pleasant Hill RoadSuite 420Duluth, GA 30096

Once we receive your agreement and payment we will send you your:

Physician Access Phone Line (via email) - The number you call 24/7 anytime you need to contact us.

Membership cards - You'll receive a welcome packet within 2 weeks) Medical Profile Link - You just click on the link and enter your base medical profile info for

you and Greer separately that stores your info on a secure database- which we use to deliver your info ahead of time anytime you have appointments)

A call from your advocate to welcome you aboard, answer your questions, and explain how it works

If you have any questions or want to reach out anytime just call your representative or888.424.0102 and leave a message and we will respond to your request within one business day. Or email [email protected]

Becoming a Member


Team Doctors Preferred AccessIndividual/Family Membership Agreement

Primary Member Name:__________________________________________________

Address:_______________________________________________________________

City:__________________ State:____________ Zip:_________________

______________________________________________________________

Please fax to 888.424.0102 or mail this COVER PAGE along with ALL of the following membership documents and signature pages.


Team Doctors Preferred Access Membership Agreement

THIS AGREEMENT (“Agreement”) is made and entered into effective _________________, 20___ (the "Effective Date") by and between Team Doctors Preferred Access, LLC ("TDPA"),a Georgia limited liability partnership, and the undersigned individual members listed on the last pages hereof (collectively and individually referred to herein as "Member(s)").

WHEREAS, TDPA is a Georgia limited liability company organized and operated for the purposes of providing Members with preferred access to a network of physicians that are often affiliated with athletic teams in most major cities in the United States and providing access to a medical history database for Members.

NOW, THEREFORE, for and in consideration of the premises and the mutual promises set forth below, the parties agree as follows:

1. SERVICES. TDPA shall establish a network of affiliated physicians ("Network") to provide services as described in this Section 1.

1.1 Preferred Access to Network. Members shall have Preferred Access to the physicians in the Network (the “Team Doctors”; and individually a “Team Doctor”). “Preferred Access” shall mean that Member receives preferential treatment from Team Doctors or a Team Doctor’s designee, including appointments that are reasonably convenient for the Member and Team Doctor, including same or next business day appointments, prior notification of arrival to decrease paperwork, and being taken back to a room quickly in order to minimize time in the waiting room. Preferred Access shall also include access to the Network referral base composed of many of the same Team Doctors that professional athletes and other celebrities may utilize.

1.2 Accessing the Network. Members shall access the Network using the toll-free call center number provided to Members by the Network. Network representatives shall be available to Members twenty four (24) hours per day, seven (7) days per week. A Member shall inform the call center of the city in which the Member is then located; the Member’s membership name or number as provided by TDPA; and Member’s contact information. The call center will promptly contact the Team Doctor or the Team Doctor’s designee in the appropriate geographical area. The Team Doctor or the Team Doctor’s designee will promptly contact the Member. When appropriate, the Team Doctor will see the Member in the Team Doctor's office on the day of or business day after the call. If a referral to a specialist outside the Network is necessary, the Team Doctor or the Team Doctor’s designee shall arrange for an appointment for Member with such a specialist.

1.3 Electronic Medical History Database. TDPA shall refer access to an electronic medical history database available for its Members. The database will house any medical information that Member makes available to the referred EMR company, as well as the records of any visits to Team Doctors or the Team Doctor’s designee, including physicals performed by Team Doctors by requesting this information from TDPA.

1.4 Accessing the Medical History Database. The member’s medical history stored within the database shall be available to members twenty-four (24) hours per day, seven (7) days per week online or according to the terms set forth by the EMR company referred to herein. Any authorized Team Doctor or Team Doctor’s designee shall be given password protected access to the medical history database in order to provide the Team Doctor with an up-to-date medical history of the Member.

2. COMPENSATION. As compensation for the Services described in Section 1 of this Agreement, Member shall pay TDPA based upon the following membership option selected by the member.

___ Team Doctors an annual, non-refundable VIP Membership fee of $___________________ for the Members listed hereon. All TDPA memberships are renewable on an annual basis.


___This membership will remain renewable at the price of $________________ for the lifetime of each Member unless terminated by either party.

Member shall pay each annual fee to TDPA within 30 days before the anniversary of the Effective Date of this Agreement. All past due amounts will accrue interest at the rate of 1.5% per month or the highest lawful rate, whichever is less. Member agrees to pay all reasonable and actual attorneys’ fees incurred by TDPA in connection with the collection of any past due amount owed to TDPA under this Agreement. If Member has not paid the annual fee on the 31st day after the anniversary of the Effective Date, TDPA shall have the option of terminating this Agreement in accordance with Section 3.3.

3. TERM AND TERMINATION.

3.1 Term. Unless sooner terminated in accordance with this Section 3, the initial term of this Agreement shall commence on the Effective Date and continue for one (1) year ("Initial Term"). Thereafter, this Agreement shall be automatically renewed for successive renewal terms of one (1) year each upon the same terms and conditions, unless and until the Agreement is terminated as provide herein. TDPA is authorized to automatically debit the credit card of the Primary Member within thirty (30) days prior to the end of any renewal period for the Membership fees of all Members listed here, unless TDPA has received written notice from the Primary Member to remove any member or that the Member has exercised the option in section 3.2. hereof.

3.2 Non-renewal. Either Party may prevent the automatic renewal of this Agreement as described in Section 3.1, by providing the other Party with written notice of its intention not to renew the Agreement at least thirty (30) days prior to the anniversary of the Effective Date.

3.3 Automatic Termination. TDPA shall have the right to terminate this Agreement immediately upon written notice to Member, if Member has not paid the annual fee in accordance with Section 2 of this Agreement.

4. DISCLAIMERS.

4.1 Medical Services. Members acknowledge that TDPA is not providing any medical services to Members. TDPA is simply providing a network within which Members may choose to receive medical services. TDPA shall not exercise control or direction over the manner or method by which any Team Doctor or Team Doctor designee provides medical services under this Agreement. Team Doctors or the Team Doctor’s designee shall be solely responsible for the provision of medical services to Members and shall exercise independent professional judgment in performing services related to the medical condition of Members. Each Team Doctor and Team Doctordesignee is an independently licensed physician who is solely and exclusively responsible for the services and advice they provide. TDPA shall not be liable in any manner for any cost, liability, claim or injury arising out of or related to services provided to or withheld from Members by a Team Doctor or a Team Doctor designee. Nothing in this Agreement shall prohibit Members from seeking medical services outside the Network, if Member so chooses. NEITHER TDPA NOR ANY TEAM DOCTOR NOR TEAM DOCTOR DESIGNEE IS AN EMERGENCY

MEDICAL SERVICE. IF MEMBER IS SUFFERING AN EMERGENCY THEY SHOULD NOT CONTACT TDPA BUT

RATHER SHOULD CALL 911 OR THE LOCAL EMERGENCY MEDICAL SERVICES IN MEMBER’S AREA.

4.2 Payment for Medical Services. Member acknowledges that the Network is not an insurance policy. Member shall be solely and exclusively responsible for all payments related to medical access services performed by a Team Doctor under this Agreement. Such payments may be made on behalf of Member by a third party payor, such as Member's health insurance plan, or by Member directly. TDPA shall not exercise any control or direction over the billing and collections policies and procedures of Team Doctors or any referred specialist.

5. COMPLIANCE WITH LAWS. The parties recognize that the health care industry is undergoing a period of rapid change, and that the laws and regulations which now exist or which may hereafter be enacted may prohibit or restrict the objectives or the procedures specified in this Agreement. The parties affirm that it is not their intent to enter into or continue any arrangement which may violate any current or future federal, state, or local law or regulation. In the event that any court, tribunal, or governing agency or authority determines that this Agreement,


or any amendment thereto or subsequent agreement between the parties, or any provision contained therein, materially violates any such law or regulation, the parties agree to amend such agreement or provision to comply with such law or regulation or, if compliance would be impractical or would substantially alter the respective rights and obligations of the parties hereto, to terminate this Agreement.

6. ASSIGNMENT, PARTIES BENEFITED. This Agreement may not be assigned by Members without the prior written consent of TDPA. TDPA may freely assign or delegate its rights and duties hereunder.

7. CONSTRUCTION. This Agreement and each provision hereof shall be severable from every other provision hereof. If any provision hereof or any remedy provided hereunder is deemed invalid or unenforceable under any applicable law, such provision shall be inapplicable and deemed omitted, but the remaining provisions hereof shall be given effect in accordance with the manifest intent hereof. The headings in this Agreement are solely for purposes of convenient reference and form no part of the agreement of the parties expressed herein. Every covenant, term and provision of this Agreement shall be construed simply according to its fair meaning and not strictly for or against any party.

8. GOVERNING LAW. This Agreement shall be construed under and governed by the laws of the State of Georgia. The parties agree that the state and federal courts of the State of Georgia shall have sole and exclusive jurisdiction and venue over any dispute or litigation which arises as a result of the rights and obligations created by this Agreement.

9. ENTIRE AGREEMENT, AMENDMENT. This Agreement, including any Attachments, constitutes the entire agreement and understanding of the parties concerning the subject matter hereof, and all prior representations of the parties, whether written or oral, are merged herein. This Agreement may be amended only by a written instrument signed by both parties hereto; provided, however, that TDPA may amend this Agreement or its Attachments by written notice to Members at least thirty (30) days in advance of the effective date of such amendments.

10. THIRD PARTY BENEFICIARY. This is an Agreement between TDPA and Members. TDPA and Member do not intend to and shall not create in any third party any right to enforce this Agreement or to collect for losses or damages under this Agreement.

11. NOTICES. Any notice under this Agreement shall be in writing and delivered either personally, by telefax transmitted to the telefax number for a party shown below (or to such other telefax number designated by notice from a party), or by mailing such notice to a party by registered or certified mail, return receipt requested, postage prepaid, and addressed to such party at the address shown below (or at such other address designated by notice from a party). Notices given hereunder shall be effective: (a) immediately, if given by personal delivery; (b) on the first business day following the date transmitted, if given by telefax; or (c) on the date of receipt shown on the return receipt, if given by registered or certified.

12. PHOTOS. Each of the undersigned persons grant to TDPA (its agents, employees, and assigns) the irrevocable right and permission to use photos of the undersigned in any TDPA publication (including, but not limited to advertising, brochures, magazines and websites), waive any right to inspect or approve such photos and release each of the foregoing persons and TDPA from any claims, demands, damages or charges relating to such use. This paragraph shall survive any termination of this Agreement and/or the undersigned ceasing to be a Member for a period of five years from the date of termination.


IN WITNESS WHEREOF, the parties hereto have executed this Agreement effective as of the Effective Date set forth above.

TDPA:

Team Doctor's Preferred Access, LLC Eric Gadlage, COO

Signature: Date of Execution:

PRIMARY MEMBER:

(PRINT OR TYPE NAME)

·____________________________________________SignatureDate: _____________________________________

Address and Phone Number:

3855 Pleasant Hill RoadSuite 420 Duluth, GA 30096678-775-6787

Member Address:

Phone:__________________________________

Email:___________________________________

SPOUSE or OTHER:

_____________________________________________(PRINT OR TYPE NAME)_____________________________________________SignatureDate______________________________________Phone:__________________________________________

DEPENDENTS:

_____________________________________________________________________________________________(PRINT OR TYPE NAME) Signature if over 18 or legal guardian

_________________________________________________________________________________________(PRINT OR TYPE NAME) Signature if over 18 or legal guardian

_____________________________________________________________________________________________(PRINT OR TYPE NAME) Signature if over 18 or legal guardian


PARENTS: ($500 additional per parent unless pricing otherwise stated)

_____________________________________________________________________________________________(PRINT OR TYPE NAME) Signature

____________________________________________________________________________________________(PRINT OR TYPE NAME) Signature



Other Members: ($500 additional per person unless pricing otherwise stated


____________________________________________________________________________________________(PRINT OR TYPE NAME) Signature




Credit Card Authorization Form

Total Membership Price:$_____________________________

Credit Card Type:

□ Amex □ Visa □ MasterCard □ Discover

Credit Card: Total Annual Payment $_________________

Credit Card Number: ______________________________________ Exp Date:_________

CVV Code on Back (3 or 4 digit number on the back of the card): ________________

Name as it appears on the Card:_________________________________________________________

Authorizing Signature: X________________________________________________________________ I agree to pay the total amount as provided herein

Billing Information/Credit Card Statement Address:

Name: ___________________________________________________________________

Street: ____________________________________________________________________

City: __________________________ State_________ Zip___________________________


HIPAA AUTHORIZATIONRELEASE OF MEDICAL RECORDS TO

TEAM DOCTORS PREFERRED ACCESS, LLC

I hereby authorize the designated records custodian of any physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, or other health care provider that has provided treatment or services to me or on my behalf (the "Covered Entity") to disclose all protected health information to employees or agents of TDPA PREFERRED ACCESS, LLC, including but not limited to:

all medical records, physicians’ records, surgeons’ records, echocardiograms, cardiac catheterizations, x-rays, CAT scans, MRI films, photographs, and any other radiological, nuclear medicine, or radiation therapy films, pathology materials, slides, tissues, laboratory reports, discharge summaries, progress notes, consultations, prescriptions, pharmacy records, records of drug abuse and alcohol abuse, HIV/AIDS diagnosis or treatment, physicals and histories, nurses’ notes, patient intake forms, correspondence, social worker’s records, insurance records, consent for treatment, statements of account, bills, invoices, or any other papers concerning any treatment, examination, periods or stays of hospitalization, confinement, diagnosis or other information pertaining to and concerning:

____________________________________________________Print Name - Primary Member

_____________________________________________________ Print Name - Spouse or Other

_____________________________________________________ Print Name - Dependent

_____________________________________________________Print Name - Dependent

____________________________________________________Print Name - Dependent

____________________________________________________Print Name - Dependant

The purpose for this release of the requested information is for the maintenance of an electronic medical record database on my behalf. This release authorizes the Covered Entity to release the entire, unredacted records, pursuant to 45 CFR § 164.508.

This authorization expires upon the termination of my Member Enrollment Agreement with TEAM DOCTORS PREFERRED ACCESS, LLC. I understand that the information disclosed under this authorization and release of medical records may be redisclosed by the person(s) or entity specified above and may no longer be subject to the same protection the information is given by the Covered Entity.


I understand that I may revoke this authorization at any time, as explained by the Covered Entity in its Notice of Privacy Practices, except to the extent that action has already been taken in reliance upon this authorization and release of medical records. I also understand that I have the right to refuse to sign this authorization and release of medical records. I also understand that the Covered Entity may not condition the provision of treatment, payment, or enrollment or eligibility of benefits on whether or not I sign this authorization, except when the release of information under this authorization is required for a health plan during initial enrollment for underwriting purposes, my participation in a research study, or when treatment is provided solely for the purpose of disclosing it to a third party such as a work-related physical performed at my employer's request.

___________________________________________ ______________________________________Primary Member Name – Please Print Signature of Primary Member

_________________________ _____________________________________Date of Birth Date

___________________________________________ ______________________________________Spouse Member Name – Please Print Signature of Spouse


___________________________________________ ______________________________________Dependent Member Name – Please Print Signature of Dependent or Guardian


___________________________________________ ______________________________________Dependent Member Name – Please Print Signature of Dependent or Guardian


___________________________________________ ______________________________________Other Member Name – Please Print Signature of Other Member


___________________________________________ ______________________________________Other Member Name – Please Print Signature of Other Member


Team Doctors Preferred Access Membership Packet

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Transcript of Team Doctors Preferred Access Membership Packet