I authorize Partida Corona Medical Center to automatically draw the re-occurring payments for 12-month commitment from the enrollment date with the monthly membership fee of $75.00 per month and will submit in writing when draw is no longer required. (There is a 3.95% credit card fee in additon to the amount due)

Terms and conditions are of a one year commitment starting from the date this form is signed and submitted. Credit card processing fees are not included in the amount above and will be charged additionally to the member each month.