Tepper-Vuong Enroll

I have engaged Eric G. Tepper, M.D. (Company) to provide non-covered primary care services and other amenities and benefits to me for a period of one year beginning on December 23, 2024, and understand that a yearly membership fee is assessed to pay for these non-covered services, amenities and benefits. As used in this Agreement, the term “Service Year” refers to the 1-year period beginning on December 23, 2024, as well as every 1-year period after that.

Select Physician(Required)

Dr. Reed Vuong

Dr. Eric Tepper (practice is full)

$2,300/year = Individual (age 45 and over as of date of enrollment)
$4,140/year = Couple (age 45 and over as of date of enrollment)
$1,700/year = Individual (age 26-44 as of date of enrollment)
$3,060/year = Couple (age 26-44 as of date of enrollment)
$900/year = Individual (age 0-25 as of date of enrollment when parent is a member)
$1,300/year = Individual (age 0-25 as of date of enrollment when parent is not a member)

Individual (age 45 and over as of date of enrollment)

Individual (age 26-44 as of date of enrollment)

Individual (age 0-25 as of date of enrollment when parent is a member)

Individual (age 0-25 as of date of enrollment when parent is not a member)

Hidden

Total members

(will be hidden, for logic only)

Individual (age 45 and over)

Price: $0.00

Couples Discount (age 45 and over)

Applied for the first additional adult aged 45 and over.

Price: $0.00

Individual (age 26-44)

Price: $0.00

Couples Discount (age 26-44)

Applied for the first additional adult aged between 26-44.

Price: $0.00

Individual (age 0-25 when parent is a member)

Price: $0.00

Individual (age 0-25 when parentis not a member)

Price: $0.00

Total

This agreement is for non-covered primary care services and other 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 materials provided to me by the Company. I understand that this Agreement can be terminated upon 30 days written notice. If I terminate, I may receive a pro-rated refund, to be determined by the Company on a case-by-case basis. If the Company terminates this Agreement, I will receive a refund of the pro-rated portion of the paid annual fee, based on the number of days that have elapsed in the Service Year. Such refund will be paid to me within 30 days after termination.

This Agreement 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 of the next payment due date. The Membership Agreement terms and annual fee amount(s) will apply to all such subsequent Service Years, unless the Company and I agree otherwise, in writing.

1st Individual (age 45 and over as of date of enrollment)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number(Required)

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email(Required)

2nd Individual (age 45 and over as of date of enrollment)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email(Required)

3rd Individual (age 45 and over as of date of enrollment)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email(Required)

1st Individual (age 26-44 as of date of enrollment)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email

2nd Individual (age 26-44 as of date of enrollment)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email

3rd Individual (age 26-44 as of date of enrollment)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email

1st Individual (age 0-25 as of date of enrollment when parent is a member)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email

2nd Individual (age 0-25 as of date of enrollment when parent is a member)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email

3rd Individual (age 0-25 as of date of enrollment when parent is a member)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email

Parent/Guardian

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number(Required)

Is this a cell number?(Required)

Yes

No

Cell Phone Number(Required)

Email(Required)

1st Individual (age 0-25 as of date of enrollment when parent is not a member)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email

2nd Individual (age 0-25 as of date of enrollment when parent is not a member)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email

3rd Individual (age 0-25 as of date of enrollment when parent is not a member)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email

Payment Schedule(Required)

I will pay annually

I will pay semianually

I will pay quarterly

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 November 7, 2023) while this Agreement remains in effect.

I understand that one-half of the full annual fee will be charged upon receipt of this form and one-half will be charged automatically at six-month intervals, continually (beginning May 7, 2023) while this Agreement remains in effect.

I understand that one-quarter of the full annual fee will be charged upon receipt of this form and one-quarter will be charged automatically at three-month intervals, continually (beginning February 7, 2023) while this Agreement remains in effect.

Your ANNUAL Payment:

This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged ANNUALLY:

Your SEMIANNUAL Payment:

This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged SEMIANNUALLY:

Your QUARTERLY Payment:

This is the amount that will be charged to your card or pulled from your bank account upon submission of this form, and will subsequently be charged QUARTERLY:

Hidden

Payment Method

Credit Card Details

Your card will be charged by Eric G. Tepper, M.D.

Credit Card Type(Required)

Visa

MasterCard

AMEX

Discover

Card Number(Required)

Expiration Month

Expiration Year

Security Code(Required)

Cardholder Name(Required)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Daytime Phone Number(Required)

Consent(Required)

I authorize Eric G. Tepper, M.D. to automatically charge my credit card the amount(s) indicated on this form.

ACH Option

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Daytime Phone Number(Required)

Bank Name(Required)

Account Type

Routing Number(Required)

Please Confirm Your Routing Number(Required)

Account Number(Required)

Please Confirm Your Account Number(Required)

Consent(Required)

I authorize Eric G. Tepper, M.D. to automatically pull from my bank account the amount(s) indicated on this form.

Digital Signature(Required)

Please type your initials to confirm this agreement.

Is the home address different from billing address(Required)

Yes

No

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

How did you hear about our practice?(Required)

Please elaborate(Required)

Date

Membership Agreement

ERIC G. TEPPER AND REED VUONG, D.O.

1st Individual (age 45 and over as of date of enrollment)

2nd Individual (age 45 and over as of date of enrollment)

3rd Individual (age 45 and over as of date of enrollment)

1st Individual (age 26-44 as of date of enrollment)

2nd Individual (age 26-44 as of date of enrollment)

3rd Individual (age 26-44 as of date of enrollment)

1st Individual (age 0-25 as of date of enrollment when parent is a member)

2nd Individual (age 0-25 as of date of enrollment when parent is a member)

3rd Individual (age 0-25 as of date of enrollment when parent is a member)

Parent/Guardian

1st Individual (age 0-25 as of date of enrollment when parent is not a member)

2nd Individual (age 0-25 as of date of enrollment when parent is not a member)

3rd Individual (age 0-25 as of date of enrollment when parent is not a member)

Credit Card Details

ACH Option