Online Enrollment | Marc Harrigan, MD

I have engaged Harrigan Medical Consulting Services, Inc. (HMCS), dba Concierge Medicine of Buckhead, to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning April 26, 2024. 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 April 26, 2024, as well as every one-year renewal period thereafter.

$2,500/year = Individual
$4,500/year = Couple
No charge for children of member (ages 12 up to 26 as of date of enrollment)

Individuals (27 and over)

Individuals (between the ages of 12 and 26)

Hidden

Total members

(will be hidden, for logic only)

Individuals (27 and over)

Price: $0.00

Couples Discount

Applied for the first additional adult over the age of 27.

Price: $0.00

Dependents

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 (H&Ds) and Frequently Asked Questions (FAQs) materials provided to me by HMCS. I understand that this Agreement can be terminated upon 30 days written notice. If the agreement is terminated, I may 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, to be determined by HMCS, on a case-by-case basis. 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 HMCS otherwise (or HMCS notifies me) within 30 days of the next payment due date.

1st Individual (27 and over)

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)

2nd Individual (27 and over)

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)

3rd Individual (27 and over)

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)

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 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 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 HMCS

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 HMCS 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 HMCS 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)

Northwest Medical Center
3280 Howell Mill Road NW, Suite 207
Atlanta, GA 30327

Patient Agreement

Marc Harrigan, MD

1st Individual (27 and over)

2nd Individual (27 and over)

3rd Individual (27 and over)

1st Individual (between the ages of 12 and 26)

2nd Individual (between the ages of 12 and 26)

3rd Individual (between the ages of 12 and 26)

4th Individual (between the ages of 12 and 26)

5th Individual (between the ages of 12 and 26)

Credit Card Details

ACH Option