Office Phone: (703) 828-0799

Office Address: 2579 John Milton Dr, Suite 300, Herndon, VA 20171

Virtual Visit Waiting Rooms

2579 John Milton Dr, Suite 300, Herndon, VA 20171

Virtual Visit Waiting Rooms

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Patient Agreement

Lifetime Internal Medicine, PLLC

Online Enrollment with Credit Card Payment Only

Step 1 of 6 - Agreement

16%

I have engaged Lifetime Internal Medicine, PPLC to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning on July 27, 2024. I understand that this Agreement will renew automatically following the end of each one year period unless I provide Lifetime Internal Medicine, PLLC with a written notice of non-renewal at least 30 days before the end of a renewal year. I further understand that I will be required to pay a yearly membership fee at the start of each renewal term for the non covered services, amenities and benefits. As used in this Agreement, the term “Service Year” refers to the one-year period beginning on the date above as well as every one-year renewal period thereafter.

$2,200/year = Individual
$4,000/year = Couple
No additional charge for the children of our member(s) ages 18 up to 26.

Doctors*

Individuals (26 and over)

Dependent child (ages 18 up to 26 years old) of an enrolled member

No additional charge for the first dependent child (ages 18 up to 26) if a parent enrolls.

$1,000/year = Each additional dependent child (age 18 up to 26) if a parent enrolls.

Hidden

Total members

(will be hidden, for logic only)

Individuals (26 and over)

Price: $0.00

Couples Discount

Applied for the first additional adult over the age of 26.

Price: $0.00

Dependent child (ages 18 up to 26 years old)

Price: $0.00

Dependent child (ages 18 up to 26 years old)

Price: $0.00

Dependent child (ages 18 up to 26 years old)

Price: $0.00

Dependent child (ages 18 up to 26 years old)

Price: $0.00

Dependent child (ages 18 up to 26 years old)

Price: $0.00

Total

This Agreement is for non-covered, non-clinical amenities and benefits as described in the Highlights & Details (H&Ds) document. I have read and understand this Agreement as well as the Highlights & Details (H&Ds) and Frequently Asked Questions (FAQs) 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 will receive a pro-rated 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 may be paid to me within 30 days after termination. Unless the Agreement is terminated as described in the first paragraph of this Agreement, 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 of the next payment due date.

1st Individual (26 and over)

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Daytime Phone Number(Required)

Is this a cell number?(Required)

Yes

No

Cell Phone Number(Required)

Email(Required)

2nd Individual (26 and over)

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Daytime Phone Number(Required)

Is this a cell number?(Required)

Yes

No

Cell Phone Number(Required)

Email(Required)

1st Individual (ages 18 up to 26 years old)

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email

2nd Individual (ages 18 up to 26 years old)

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email

3rd Individual (ages 18 up to 26 years old)

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email

4th Individual (ages 18 up to 26 years old)

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Daytime Phone Number

Is this a cell number?(Required)

Yes

No

Cell Phone Number

Email

5th Individual (ages 18 up to 26 years old)

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

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 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 and one-half will be charged automatically at six-month intervals, continually 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 and one-quarter will be charged automatically at three-month intervals, continually 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 upon submission of this form, and will subsequently be charged QUARTERLY:

Hidden

Payment Method

Credit Card Details

Your card will be charged by Lifetime Internal Medicine, PLLC.

Credit Card Type(Required)

Visa

MasterCard

AMEX

Discover

Card Number(Required)

Card Number(Required)

Expiration Month

Expiration Year

Security Code(Required)

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 Lifetime Internal Medicine, PLLC, 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 Lifetime Internal Medicine, PLLC, 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)

Δ

If you have further questions, please call our Patient Information Line at 571-266-1170. We will be happy to assist you.

Lifetime Internal Medicine
(703) 828-0799
2579 John Milton Dr #300, Herndon, VA 20171
© 2020 |

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Dr. Kaneriya
Dr. Marathe
Dr. Lim

Dr. Kaneriya
Dr. Marathe
Dr. Lim

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