Enroll

I have engaged Jason Faller, MD (Company) to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning on December 20, 2021. I understand that this Agreement will renew automatically following the end of each one-year period unless I provide the Company with a written notice of non-renewal at least 30 days before the end of a Service Year. I further understand that I will be required to pay a yearly membership fee at the start of each renewal term for these non-covered services, amenities, and benefits. As used in this Agreement, the term “Service Year” refers to the one-year period beginning on December 20, 2021, as well as every one-year renewal period thereafter.

This Agreement is for non-covered, non-clinical amenities and benefits as described in the Highlights & Details document. I have read and understand this Agreement as well as the Highlights & Details and Frequently Asked Questions documents that are considered a part of this Agreement. I understand that this Agreement can be terminated upon 30 days written notice and that, if the Agreement is terminated, I may receive a prorated refund of the annual fee I paid, based on the number of days that have elapsed in the Service Year (which will be determined by the Company on a case-by-case basis). Such refund will be paid to me within 30 days after termination. Unless the Agreement is terminated as provided in the first paragraph of this Agreement above, it will automatically renew for subsequent Service Years under the same payment terms unless I notify the Company otherwise (or the Company notifies me) within 30 days prior to the next payment due date.

I understand that the full annual fee will be charged upon receipt of this form and the full annual fee will be charged automatically at 12-month intervals, continually (beginning December 20, 2022) while this Agreement remains in effect.