|
Retainer Fee Agreement
Once your Retainer
Fee Agreement and fee have been received, you will be
notified that you have been accepted into your
physician’s practice. In the event your physician’s
practice is full, you may place your name on a
waiting list. Alternately, you may be able to
transition to an associate’s practice on a
space-available basis. Please complete the information
below:
Your name: _______________________________________
Date of Birth: _________________
Your physician’s name:
__________________________________
Name(s) of any children (ages 14 – 25) to be included:
___________________________________
Have they already been seen? Y or N (circle one).
If so, by which physician: _________________
Your email address: __________________________________
Daytime telephone number: ____________________________
Please indicate your preferred schedule of payment:
□ Paid annually, in full: one payment of $2,000 plus
$500 for each child ages 14 – 25
□ Paid semi-annually: initial payment of $1,050 plus
$500 for each child ages 14 - 25; second
payment of $1,050 due in 6 months. You will be invoiced
for your second payment.
Please indicate your preferred method of payment:
□ Personal check, made payable to your physician
(please circle):
-
Harry A. Oken, MD
-
Jonathan S. Fish,
MD
-
Kevin E. Carlson,
MD
-
Randal P. Riesett,
MD
-
·Michael
C. Albert, MD
□ Credit Card (circle one: Visa MasterCard
Discover American Express)
Card Number:
___________________________________________________
Expiration Date: ___________________
Security Code: _______________
ATTN Flexible Spending or Health Savings Account
Users: (please check box if appropriate)
□ If your plan requires your Retainer Fee payment be
dated in 2009, you may make your payment on January 1,
2009. To reserve your space, a $500 deposit is
required; this must be in the form of a check (made
payable as above) which will be held and returned to you
upon payment from your HSA or FSA.
Return your completed form and payment by one of the
following methods:
□ Mail to: Charter Internal Medicine, 10700 Charter
Drive, Suite 200, Columbia, MD 21044
□ Fax to: 410-910-2310 (credit card payments only)
□ Drop off at the above address
My signature below authorizes my credit card payment
and confirms that I am willing to receive unencrypted
emails from Charter Internal Medicine:
Signature:
_________________________________ Date:
_______________________
Medicare patients must complete
the reverse side of this page before we can accept your
payment! ►(over)
| 
