Carolina Preventive Medicine
Membership Agreement

or fill out application below:

This Membership Agreement specifies the terms and conditions under which you, the undersigned Member, may participate in the Carolina Preventive Medicine Physicians Program.  This Agreement will become effective as of the date set forth by Carolina Preventive Medicine Physicians at the end of this Agreement (the “Effective Date”).



1. Carolina Preventive Medicine Physicians Program

The Program’s annual fee encompasses the following services:

♦  Annual Preventive Care History & Physical Examination

♦  Comprehensive Wellness Plan

♦  All Office Visits During the Year

♦  Electrocardiogram

♦  Nutritional Education

♦  Laboratory Assessment (at the time of physical exam)

  • Comprehensive Metabolic Panel

  • Complete Blood Count

  • Prostate Specific Antigen (for men)

  • Thyroid Stimulating Hormone

  • Lipid Profile

  • Urinalysis

2. Annual Membership Fee

Each member will pay an annual fee of $3000.00

3. Financial Procedures for Services

Carolina Preventive Medicine Physicians is an out-of-network provider for insurance and does not participate with or file Medicare. As a courtesy we will file claims for all non-Medicare members so that they may receive reimbursement from their insurance carrier for their office care.

4. Additional Services and Benefits

A variety of additional services and benefits are offered under this Program.  These services are subject to insurance filing if applicable. The Member’s financial responsibility is capped at a particular dollar amount depending upon the service. 

5. Medical Care Services Excluded from Annual Membership Fee

The annual membership fee specified herein covers only the defined services. 

All other services are excluded from this Agreement, such as diagnostic imaging, specialist visits, additional laboratory services, hospitalization, etc.  All other services may be filed to your insurance if applicable, and you will ultimately be responsible for any additional balances, not medically necessary services, non-covered services, deductibles, coinsurance, and co-payments.

6. Renewals and Termination

The annual membership fee covers a period of one (1) year.  In order to renew membership the annual fee must be paid prior to the anniversary of the Effective Date.  (For example, if the anniversary Date is September 15 then you must renew on or before September 14 the following year).  If the annual renewal fee is not received by the anniversary date, the membership will be terminated. You or Carolina Preventive Medicine Physicians may terminate this Agreement at any time upon 30-days prior written notice.  If you or Carolina Preventive Medicine Physicians terminate this Agreement for any reason, you will be entitled to a prorated refund of any unused portion of your annual membership fee.  Such prorated refund will be based on the number of months you have participated in the Program, and whether you received your Annual Preventive Care Physical Examination, Comprehensive Wellness Plan, and Services.  The amount of any such refund will be determined by the Program. Upon Carolina Preventive Medicine Physicians receipt of this Agreement and the membership fee, Carolina Preventive Medicine Physicians shall have the option, in its sole and absolute discretion, not to accept this Agreement and to return your payment to you (e.g., due to limitations on the number of Members).  The annual membership fee is subject to change on an annual basis.

7. Entire Agreement

Each of the undersigned agrees to the terms of this Membership Agreement, all of which are expressed herein.  There are no promises or representations except as set forth herein.

8. Notices

Any communication required or permitted to be sent under this Agreement shall be in writing and sent via certified mail, return receipt requested, to the addresses set forth below. Any change in address shall be communicated in accordance with the provisions of this section.

9. Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of South Carolina.

10. Member Billing

You may pay for your membership and additional fees with cash, check or credit card.  We accept Visa, MasterCard, and American Express. Please make your checks payable to Carolina Preventive Medicine Physicians.

I understand that I am responsible for payment of deductibles, co-payments, coinsurance, medically unnecessary services, and /or non-covered services that are not included in the Services provided by the Carolina Preventive Medicine Physicians Program.

I hereby authorize the physician to release all medical information necessary for continuity of care, and payment of balances.

I certify that I have read, understand and agree to the terms and conditions of this Agreement: