Membership Based Practice Fee Form for New Perspectives Health Care
Payment for year : 2019
Individual Membership: $150 each individual member
Patient name: ________________________________ Date of birth: ____________________
Address: __________________________________________________________________________________
OR:
Family-Unit Membership: $350 for family
(Family is defined as members in same household with same insurance policy, ie: parents and children 16 to 26 yrs old):
Patient name: ________________________________ Date of birth: ____________________
Patient name: ________________________________ Date of birth: ____________________
Patient name: ________________________________ Date of birth: ____________________
Patient name: ________________________________ Date of birth: ____________________
Patient name: ________________________________ Date of birth: ____________________
Family address: ____________________________________________________________________________
Make checks payable to New Perspectives Health Care: Check #: ___________________
(A $50 service fine will be added for checks returned by the bank)
Mail to New Perspectives Health Care, 13A Main St., Suite 7, Sparta, NJ 07871; ℗ 973.727.0355
Or pay by Credit (We do not take American Express)or Debit card
Card#: _______________________________, Expiration date: ______ or call to give # to staff
**All previous account balances must be paid in full and be current**
Patient acknowledgement statement:
I understand that I am paying for a 1 year (February 1st through January 31st of the following year) membership to continue as a patient at New Perspectives Health Care. Membership, at this time, is only extended to current patients. The Membership fee is for one 12-month period from date of payment. You will be responsible to maintain your membership fee each year that you intend to participate in.
Signature: _______________________________________________ Date: _______________________
Printed name: _____________________________________