Membership Terms of Agreement                                                                                 Date: ________________

The Vanderbilt Wellness Membership package allows the patient to pay a standard monthly fee in order to access discounted services and products at the Vanderbilt Wellness clinic. This is not a substitute or replacement for insurance. As a Direct Primary Clinic, or DPC, we do not accept any form of insurance. If the patient desires, we can put their insurance on file so that the labs and pharmacies can bill their insurance. Any insurance related bills will not be rendered from The Vanderbilt Wellness Clinic and concerns for those bills should be brought to the attention of the pharmacy or lab that billed your insurance. The goal of a DPC is to remove the complications of billing insurance. Insurance companies require authorizations and may not cover the services you would be receiving at The Vanderbilt Wellness Clinic. 

Patient Responsibility 

By signing this agreement, I, the patient, agree to ensure prompt monthly payment to maintain my membership. I am aware that the billing cycle will charge me $ 75.00 (for a single account) or $135.00 (For a couples’ account) every month with a one time enrollment fee of $50 on the first cycle. If there is a change to my card information, I will do my best to inform the clinic as soon as possible so that it may be updated before the next billing cycle. If I wish to cancel my membership, I will let the clinic know before the next billing cycle begins. I am aware that I will not be reimbursed for the remainder of the month that I have already paid for and may continue to use the clinic’s services during that time. I have received a list of services and products with their prices and agree to pay them at time of visit. These fees and services cannot and will not be billed to my insurance (Medicaid and Medicare included). I understand there is a $10 late fee for monthly payments and that If I am unable to make a monthly payment, a one time deferral to the next month will occur. After the one time deferral, my membership will be cancelled and I will have to pay an enrollment fee in order to regain membership.

Clinic Responsibility

By signing this agreement, the clinic agrees to provide the patient with all services and products available at a predetermined discounted price. These prices have been provided to the patient for review. Any changes to services and products provided such as availability and price will be emailed or given to the patient with a minimum 21 days notice. The clinic agrees to honor the patient’s membership and cancel the payments as soon as it is requested. 

Patient Name (Print)  : _________________________________________________________

Patient Date of Birth  : _________________________________________________________

Patient Signature : ____________________________________________________________

Clinic Representative : ________________________________________________________

Representative Signature : _____________________________________________________