Lown Cardiology Group

I have engaged Boston Heart, LLC, dba Lown Cardiology Group (Company) to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning on December 22, 2024, including the ability to connect promptly to my physician at Lown Group. I understand that this Agreement will renew automatically following the end of each one-year period unless I provide the Company with a written notice of non-renewal at least 30 days before the end of a renewal year. I further understand that I will be required to pay a yearly membership fee at the start of each renewal term for the non-covered services, amenities and benefits. As used in this Agreement, the term “Service Year” refers to the one-year period beginning on December 22, 2024, as well as every one-year renewal period thereafter.

$10,000/year = Individual, Internal Medicine

Individuals

Hidden

Total members

(will be hidden, for logic only)

Individuals

Price: $0.00

Total

This Agreement is for non-covered, non-clinical amenities and benefits as described in the Highlights & Details (H&D) document. I have read and understand this Agreement as well as the Highlights & Details (H&D) and Frequently Asked Questions (FAQ) documents that are considered a part of this Agreement. I understand that this Agreement can be terminated upon 30 days’ written notice and that, if the Agreement is terminated, I may receive a refund up to and not exceeding $1500, based on the number of days that have elapsed in the Service Year (which will be determined by the Company on a case-by-case basis). Such refund will be paid to me within 30 days after termination. Unless the Agreement is terminated as provided in the first paragraph of this Agreement above, it will automatically renew for subsequent Service Years under the same payment terms, unless I notify the Company otherwise (or the Company notifies me) within 30 days of the next payment due date.

Payment Schedule(Required)

I will pay annually

I will pay semianually

I understand that the full annual fee will be charged upon receipt of this form and the full annual fee will be charged automatically at 12-month intervals, continually, from my Service Year, while this Agreement remains in effect.

I understand that one-half of the full annual fee will be charged upon receipt of this form and and one-half will be charged automatically at six-month intervals, continually, from my Service Year, while this Agreement remains in effect.

Your ANNUAL Payment:

This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged ANNUALLY:

Your SEMIANNUAL Payment:

This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged SEMIANNUALLY:

Hidden

Payment Method

Credit Card Details

Your card will be charged by Lown Cardiology Group

Credit Card Type(Required)

Visa

MasterCard

AMEX

Discover

Card Number(Required)

Expiration Month

Expiration Year

Security Code(Required)

Cardholder Name(Required)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Daytime Phone Number(Required)

Consent(Required)

I authorize Lown Cardiology Group to automatically charge my credit card the amount(s) indicated on this form.

ACH Option

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Daytime Phone Number(Required)

Bank Name(Required)

Account Type

Routing Number(Required)

Please Confirm Your Routing Number(Required)

Account Number(Required)

Please Confirm Your Account Number(Required)

Consent(Required)

I authorize Lown Cardiology Group to automatically pull from my bank account the amount(s) indicated on this form.

Digital Signature(Required)

Please type your initials to confirm this agreement.

Is the home address different from billing address(Required)

Yes

No

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

How did you hear about our practice?(Required)

Please elaborate(Required)

Membership Agreement

Joel Katz, MD, Boston Heart, LLC

1st Individual

2nd Individual

3rd Individual

4th Individual

5th Individual

1st Individual (between the ages of 18 and 26)

2nd Individual (between the ages of 18 and 26)

3rd Individual (between the ages of 18 and 26)

4th Individual (between the ages of 18 and 26)

5th Individual (between the ages of 18 and 26)

6th Individual (between the ages of 18 and 26)

7th Individual (between the ages of 18 and 26)

Credit Card Details

ACH Option