• MEMBERSHIP APPLICATION

    To apply for program membership, please fill out this simple online form.  

    If you wish to instead fill out a paper copy of the form, please drop by our office to do so.  We are located in the SmoothieEspresso strip mall next to the Alvin WalMart in the "HEALTHWORKS CLINIC". (click for map)

    After filling out the form, you will receive a confirmation email with further instructions. 

    In case of any questions, please email membership@Alvin-Health.com, call us during office hours at 281-585-3505 or simply stop by to see us.

    Thank you!

     

     

     


  • Enter Participant Information 

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  • Notes:
    Discount will be applied at time of application processing.
    Discount will reduce monthly premium in the amount of $10/month.
    Discounts valid on premiums in excess of $10 per month only.
    Discount periods run through December 2020 only.

  • Sign the Form as the Authorized Payer

    By signing below, you certify that the information provided is accurate and indicate that you understand and accept the terms of the Health Membership Program for the individuals listed above.  If accepted into the program, you agree to be responsible for payment of program costs and will give authorization for automatic debit of your account until you cancel your membership.

  • Review Program Details

    The following summarizes the benefits & details of your Health Program Membership

    Unlimited Appointments + In-Clinic Lab Tests – with no extra charges

    • Your plan includes unlimited appointments on medically-necessary basis
    • Your plan includes unlimited in-clinic lab tests for your condition as prescribed by our providers (see website for listing)
    • Your plan includes 30-minute appointments only; extra time for extended consultation, multiple conditions, etc. is at a cost of $20 per 15 minutes
    • Appointments during office hours on as-available basis ( emergencies etc should visit local Urgent Care or hospital )
    • Extra $25 charge for no-show or same-day appointment cancellations
    • Be on time - coming 15mins late may result in cancellation and $25 fee

    Definitions of SINGLE, COUPLE & FAMILY

    • SINGLE = 1 person, adult or child, any age
    • COUPLE = 2 people, married or living together in civil partnership
    • FAMILY = 1 or 2 parents plus any number of natural or adopted children under age 21 living with you at same address

    Program Acceptance

    • Acceptance into the program will be confirmed following our review of your application
    • In case of mismatch between the visit history provided on your application and medical history, we reserve the right to change your premium or cancel your membership
    • Program benefits begin following payment of the administration fee and first month's payment

    Premium Info

    • The monthly premium is set based on the information that you have provided on your application
    • If your actual appointments are more frequent than indicated on your application, then your premium will be adjusted upwards to match
    • We reserve the right to make premium adjustments over time; in case of any change, we notify you in advance of any change to your automatic withdrawal

    Cancellation / Termination

    • You may cancel your program participation at any time and for any reason – without penalty and without cost;  however, there is also not any refund of fees paid
    • Cancellation is effective immediately from the date you email us  your  request to cancel
    • If you cancel within 30 days of sign-up, you agree to pay the difference between any visits made and our standard rates via ACH withdrawal
    • We may cancel your membership in case of non-payment or abuse of visit privileges (eg, visits without medical reason)

    Reactivation & Payment  (The Fine Print)

    • Reinstatement after cancellation or termination requires payment missing monthly fees plus the admin fee
    • Membership fees are by auto-charge only – no cash or check payment except for month #1
    • All premium and admin fees paid are non-refundable

    Exclusions, Insurance & Possible Program Changes (more fine print)

    • All plans exclude separately-priced items including diagnostic tests, x-rays or other imaging, separately-priced tests, immunizations or shots, supplies (stitches kit, etc)  (see pricing page on website for details)
    • No receipt of payment is made for clinic visits; these can therefore not be submitted to your insurance for reimbursement
    • Although we don’t plan to change program details, we are free to change this program at any time – however, in case of any cost change, we will provide at least 1 month notice via email - all other changes will be noted on website 
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