Alvin Health New Patient App (Standard 101817)

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

Your Name *

First Name Last Name

First Name *

Last Name *

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cellphone: *

Area Code Phone Number

E-mail *

Confirmation Email

How did you hear about our program? *

From our clinic staff, whom may we thank?

From a friend or relative, whom may we thank?

Plan Selection *

SINGLE COUPLE FAMILY

Spouse / Partner Name

First Name Last Name

Number of Children to be included on plan (must be living with you and under age 21)

Child #1

First Name Last Name

Child #2

First Name Last Name

Child #3

First Name Last Name

Child #4

First Name Last Name

Child #5

First Name Last Name

Child #6

First Name Last Name

How many Doctor + Urgent Care Visits for all people in your group in the last 6 months? *

Certification *

I certify that the number of visits indicated above includes all visits to both doctor and/or urgent care centers over the last 6 months for all people to be covered in my program membership.

Plan minimum premium

One-time Admin Fee, $

Monthly Premium, $/month

Do you have a DISCOUNT CODE?

Yes No

Enter your discount code here - if valid, your premium will be reduced by $10/month

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

Signature *

Clear