PROSPERITY PRIMARY CARE, PERSONALIZED MEDICINE

I have engaged Prosperity Primary Care, Personalized Medicine (Company) and its physician Anjali Sues, M.D., 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 thereafter.

$2,000/year = Individual Age 40+
$1,500/year = Individual Age 18-39
$1,500/year = Dependent Age 18-26
No Charge = First 2 dependent children of an enrolled member between the ages of 18 and 26
(A 10% discount for the first 2 adults 18 and over who live in the same household will be applied)

Individuals ages 40 and over

Price: $2,000.00

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Individuals 40+

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Individual members between the ages of 18 and 39

Price: $1,500.00

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Individuals 18-39

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Dependent children of enrolled members between the ages of 18 and 26

Price: $1,500.00

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Dependants (Ages 18-26)

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Discount 2x(40+)

Discount 2x (40+)

Price:

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Discount (40+) + (18-39)

Price:

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Discount 2x(18-39)

Price:

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Discount one dependant

Price:

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Discount two dependants

Price:

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total non dependents

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Cost for Individuals 18+

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Total dependent members

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Cost for dependants 18-26

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Annual, semiannual, and quarterly payment options are available.

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Total

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 may 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.

1st Individual (Ages 40+)

Name*

First Last

Date of Birth*

Gender*

Daytime Phone Number*

Is this a cell number?*

Yes

No

Cell Phone Number

Email*

2nd Individual (Ages 40+)

Name*

First Last

Date of Birth*

Gender*

Daytime Phone Number

Is this a cell number?*

Yes

No

Cell Phone Number

Email*

3rd Individual (Ages 40+)

Name*

First Last

Date of Birth*

Gender*

Daytime Phone Number

Is this a cell number?*

Yes

No

Cell Phone Number

Email*

4th Individual (Ages 40+)

Name*

First Last

Date of Birth*

Gender*

Daytime Phone Number

Is this a cell number?*

Yes

No

Cell Phone Number

Email*

1st Individual (Ages 18 – 39)

Name*

First Last

Date of Birth*

Gender*

Daytime Phone Number

Is this a cell number?*

Yes

No

Cell Phone Number

Email*

2nd Individual (Ages 18 – 39)

Name*

First Last

Date of Birth*

Gender*

Daytime Phone Number

Is this a cell number?*

Yes

No

Cell Phone Number

Email*

3rd Individual (Ages 18 – 39)

Name*

First Last

Date of Birth*

Gender*

Daytime Phone Number

Is this a cell number?*

Yes

No

Cell Phone Number

Email*

4th Individual (Ages 18 – 39)

Name*

First Last

Date of Birth*

Gender*

Daytime Phone Number

Is this a cell number?*

Yes

No

Cell Phone Number

Email*

1st Dependent (18 – 26)

Name*

First Last

Date of Birth*

Gender*

Daytime Phone Number

Is this a cell number?*

Yes

No

Cell Phone Number

Email

2nd Dependent (18 – 26)

Name*

First Last

Date of Birth*

Gender*

Daytime Phone Number

Is this a cell number?*

Yes

No

Cell Phone Number

Email

3rd Dependent (18 – 26)

Name*

First Last

Date of Birth*

Gender*

Daytime Phone Number

Is this a cell number?*

Yes

No

Cell Phone Number

Email

4th Individual (18 – 26)

Name*

First Last

Date of Birth*

Gender*

Daytime Phone Number

Is this a cell number?*

Yes

No

Cell Phone Number

Email

Payment Schedule*

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:

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Payment Method

Credit Card Details

Your card will be charged by Dr. Sues, LLC

Credit Card Type*

Visa

MasterCard

AMEX

Discover

Card Number*

Expiration Month

Expiration Year

Security Code*

Cardholder Name*

Billing Address*

Street Address Address Line 2 City State ZIP Code

Daytime Phone Number*

Consent*

I authorize Dr. Sues, LLC to automatically charge my credit card the amount(s) indicated on this form.

ACH Option

Billing Address*

Street Address Address Line 2 City State ZIP Code

Daytime Phone Number*

Bank Name*

Account Type

Routing Number*

Please Confirm Your Routing Number*

Account Number*

Please Confirm Your Account Number*

Consent*

I authorize Dr. Sues, LLC to automatically pull from my bank account the amount(s) indicated on this form.

Digital Signature*

Please type your initials to confirm this agreement.

Is the home address different from billing address*

Yes

No

Home Address*

Street Address Address Line 2 City State ZIP Code

How did you hear about our practice?*

Please elaborate*

Membership Agreement