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Terms of service

This patient membership agreement (the “agreement”) specifies the terms and conditions under which you the undersigned patient (“Patient”) may participate in the program (“Program”) offered by “My Doctor & Me” and your physician. This agreement will become effective either on the date your physician commences the program or the date of your signature on this Agreement, whichever is later (the “Effective Date”).  

  1. Program – The program’s annual membership fee encompasses the following “Services”  
  1. Annual Wellness program, including advanced wellness screenings, diagnostics, and wellness counseling  
  1. Personal health record  
  1. Direct access to your physician 
  1. Annual Patient Membership Fee Levels:  
  • $4,250 Diamond Level (All-inclusive care and prevention package) 
  • $3,500 Platinum Level (Total care and prevention package) 
  • $2,000 Platinum Silver Level* (Total care and prevention for those with Medicare as primary insurer [does not include Medicare replacement plans]) 
  • $1,850 Executive Gold Level (Basic Health and wellness package, (Executive Gold “Lite”18 -35 years old $1250* Does not include stress testing and echocardiogram) 
  • $850* Aicher Level 
  • $500* Member Level 
  1. The Relationship Between Physician and My Doctor & Me – You understand and acknowledge that each My Doctor & Me affiliated physician (“Physician”) is an independent contractor and not the agent, servant, or employee of “My Doctor & Me”. You further agree and understand that My Doctor & Me does not provide, supervise, or control the care that you receive from a physician. Rather, your care is furnished and directed solely by the “Physician” who exercises his/her own medical judgement in his/her practice of medicine. My Doctor & Me is not responsible for the judgement nor conduct of any Physician who renders service to you. 
  1. Renewals and Termination – The annual fee covers a period of one (1) year (the “Term”). Failure to pay the renewal Annual fee prior to the anniversary of the “Effective” date shall result in termination of your participation in the Program. (For example, if the effective date is May 15, 2023, you must renew on or before May 14, 2024. You or your Physician may terminate this agreement at any time upon thirty (30) days written notice. If you or your Physician terminates this agreement for any reason prior to receiving all your services, you will be eligible for a prorated refund. If you have received your services, you will not be eligible for a refund, and you will be responsible for the balance of the Annual Fee. Upon your Physician’s receipt of this “agreement” and the Annual Fee, your Physician shall have the option in its sole and absolute discretion, not to accept the Agreement and to return your payment to you. (e.g., due to limitation on the number of patients). Unless otherwise terminated this agreement shall automatically renew for an additional one-year period upon expiration of each term. 
  1. Medical Services Excluded from Annual Fee – The Annual Fee specified herein shall cover only the defined “services” described in Section above. Except for your included member services, you will be financially responsible for paying all healthcare and medical care services received by you from your  

Physician and his/her staff at the discounted cash rates specified in your membership level. Your Physician may bill you or Medicare, as the case may be, for those healthcare or medical services not provided to you according to the membership agreement. The membership enables your Physician to offer same day/next day/telephonic services at your convenience that start on time, are unhurried, 24/7 access to healthcare team by cell phone / text* of clinical staff and your physician. (*as specified by your membership level)  

  1. Co-Payments – The My Doctor & Me annual fee does not affect co-payments, deductibles, or co-insurance that you are required to pay pursuant to the terms of your insurance coverage. This is not insurance, you will continue to be financially responsible for any co-payments, coinsurance, or deductible amounts required by your insurers.  
  1. The undersigned agrees to the terms of this Agreement, all of which are expressed herein. There are no promises or representations except set forth herein. 
  1. Notices – Any communication required or permitted to be sent under this Agreement shall be in writing and sent via U.S. mail to the addresses set in this Agreement. 

My Doctor & Me: 

35 W Church St Suite 103 

Jasper, GA 30143 

385 Lum Crowe Rd 

Roswell, GA 30075 

You: 
Street Address ____________________________ 

State    ____________________________ Zip__________