MV -YA17:: : fQ!25">6:: J H >$D"PF&PG:: P 4  5 5Bf:lP:SS&L'(jQ)6+:*r<,2@-O~Q.G/Q0.62<1(<6v<v<7Q8 Q:R9gS; S<\F>M? 3Pz /YɇYBonilla______________________ShawnNormal Balloon Text Char NormalHeading 11 ]Heading 22  Heading 33  Balloon Text  @  L33%Elite Medical Program Enrollment Form By HealthCare Stat, LLCThis medical coverage plan is a service provided by HealthCare Stat, LLC. This agreement is to make available services that we offer in office more accessible at a more predictable and reasonable rate. You understand that this coverage is not insurance and will not be recognized at any other facility. We are offering a valuable service to our patients with subscription term of 12 months. 1Medicare, Medicaid, and commercial Insurance participants are not eligible. It is your responsibility to inform us if you obtain these services, so we can excuse you from our program (Possible early termination fee may apply). This restriction does not apply to those with commercial major medical plans.qAt the end of your contract you may renew for continuation of service or choose to discontinue the plan. Your prices and benefits are locked in for the duration of your plan but are subject to changes at the end of your term. You understand that we will not file with a commercial insurance if enrolled with our plan. We do maintain the right to cancel your plan at any time and maintain the right to refuse service to any persons found to be abusive, disruptive, or harmful to healthcare stat. =The services provided are available at all of our locations: /821 E. Veterans Memorial Hwy Blanchard OK 7301051928 S. 4Bth耀耀 Street Chickasha OK 73018+1505 S. Mission St. Ste A Anadarko OK 73005%2120 N. Main Ste B Newcastle OK 730655(Coming soon) 301 E. Cherokee Ste F Lindsey OK 73052 QWe recommend our patients maintain a major medical policy for hospital stays, surgeries, specialist, or any other major medical expenses outside of our services.6We maintain the right to choose the best medication options or plans of care to our patients and work to make it a collaborative process. Referrals and recommendations to higher levels of care to rule out the possibility of serious or life threatening conditions will be made at the discretion of the provider.To establish care with us and choose us as your primary care provider for management of chronic illness (i.e. diabetes, high blood pressure, hypothyroid) regular labs, X-rays, EKG, may be required. Every patient is different and so are their needs. Your care is our highest priority and we will always be more than happy to take the time and explain our recommendations and/or concerns. Controlled substances are excluded from the care programs. A one-time enrollment fee of $60.00 for each member is due at the beginning of your term. Upon enrollment the first month’s payment of the level of service you choose is due. A $5.00 office fee will be due at each visit. Auto debit to credit card or checking account will be required. The Basic:Unlimited visits to any of our locations, annual wellness exams, prescriptions written as needed, annual flu shot, annual sport physical, finger glucose level, urine test (UA), urine pregnancy test (2 a year), a rapid flu test, a rapid strep test, a rapid RSV test, basic wound care (dressing and topical antibiotics), pelvic exam with pap every three years in >21. Every 5 years with normal results and Neg HPV.ACost: First family member is $65.00 per month and additional members are $ 45.00 per month. $5.00 office co-pay at time of visit. The Complete: Includes the basic plus:ZTotal wound care (staples, sutures, steri-strips, derma bond). Dressing changes and topical antibiotics. X-rays (In House), Splinting and slings, Abscess I and D (packing) with local included, foreign body removal, Eye care with woods lamp and kit, Ingrown toenail repair with post op shoe x 1 year, IV fluids and catheter, Destruction of skin lesion x 2 year (outside pathology lab not included), Breathing treatments nebulizer and medications for in office treatment included, Standard basic lab x 1 year (CBC,CMP,TSH T3T4,Hemacult screen, PSA >50) included. EKG x2 year included. (In office medications included: Diphehydramine, Steroids, Zofran, tylenol, motrin, phenergan, and pepcid). DCost: First family member is $75.00 per month and additional members are $60.00 per month. $5.00 office co-pay due at the time of visit. The Premium:*This includes the basic and complete plus:Basic in house labs up to every 90 days including PT/INR., All of our office procedures including ear wax removal, trigger point injections, ring removal, nurse maid’s reductions, and many more, referral scheduling, extended hours online consults if needed with telemedicine. 1aCost: First family member is $90.00 per month and additional family members are $65.00 per month.(ÜÜ Ü*Must be immediate family to be included. Children must be under 21 years of age to qualify for discounted rates. Plans can be mixed ( i.e. father with complete care pays $75.00 per month and his child with basic care will cost $45.00 per month)耀耀 耀.耀耀 耀 耀耀 耀n HealthCare Stat representive filing subscription:'NName__________________________________Signature_______________________________Date__________________________"CMedical Home Clinic Locations______________________________________ Family member one: 8Date______________ Plan expires_________________" CName_______________________________DOB________________Age__________) RSignature__________________________________Plan________________Cost_______________ Family member two: 8Date______________ Plan expires_________________" CName_______________________________DOB________________Age__________) RSignature__________________________________Plan________________Cost_______________ Family member three: 8Date______________ Plan expires_________________" CName_______________________________DOB________________Age__________) RSignature__________________________________Plan________________Cost_______________ Family member four: 8Date______________ Plan expires_________________" CName_______________________________DOB________________Age__________) RSignature__________________________________Plan________________Cost_______________ Family member five: 8Date______________ Plan expires_________________" CName_______________________________DOB________________Age__________) RSignature__________________________________Plan________________Cost_______________ Family member six: 8Date______________ Plan expires_________________" CName_______________________________DOB________________Age__________) RSignature__________________________________Plan________________Cost_______________+Total cost to be debited x 1 ______________-Total cost to be debited monthly_____________/=v vj;*/=v vj;+K/=v vj; Z6|r*x<<BVj~` !,!X! $$$$.%X&&&4(H(\(p(((((B***.+B+h++ ,r,,,<---.n...H//0.0z0081^112h2|222/=v@dddddd PY@k4H#Brother HL-L6200DHHh .Color 24I}>Color 25=Color 26O =Color 27PM !?Color 28Yp!?Color 29d`<Color 30K<Color 31F<Color 32P<userJ-Table\<$O!\S$z($,O!:N!N!N! *sFigure\<$O!\S$z($,O!:N!N!N! *sPicture\<$O!\S$z($,O!:N!N!N! *s\OPMYdKF3ffffd<d<d<ddddd d d Numbered list 1h8o  oxHoh+o  22hh22@@2222 22 22 22 22 22B 22 22 22Times New RomanASimSunArialSymbolCourier NewWingdingsCalibriTahomaBook AntiquaCambria<<<<dd2ddT2DT  Unknownv00