Lown Cardiology Group | Concierge Cardiology of Chestnut Hill, MA

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 July 27, 2024, including the ability to connect promptly to my physician of choice at Lown Cardiovascular 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 July 27, 2024, as well as every one-year renewal period thereafter.

FOR MEMBERSHIP DURING THE SERVICE YEAR, I AGREE TO PAY THE COMPANY:*

$5,000/year = Individual Cardiology

$10,000/year = Individual, Cardiology/Internal Medicine

Total (Annually):

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 prorated refund of the annual fee I paid, 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.

Member #1

Name (Member #1)*

First Last

Select Provider (Member #1)*

Dr. Bilchik

Dr. Blatt

Dr. Kelley-Hedgepeth

Dr. Lee Lewis

Dr. Ravid

Email (Member #1)*

Main Contact Phone Number*

Is the Main Contact Phone Number above a mobile phone or a landline?*

Mobile Phone

Landline

Mobile Phone Number (Member #1)

Date of Birth (Member #1)*

Gender (Member #1)*

Is Member #1's home address different than the billing address?*

Yes

No

Home Address (Member #1 - if different from billing address)*

Street Address Address Line 2 City State ZIP Code

Digital Signature (Member #1)*

Please type your initials to confirm this agreement.

Member #2

Name (Member #2)*

First Last

Select Provider (Member #2)*

Dr. Bilchik

Dr. Blatt

Dr. Kelley-Hedgepeth

Dr. Lee Lewis

Dr. Ravid

Email (Member #2) - OPTIONAL

Mobile Phone Number (Member #2)

Date of Birth (Member #2)*

Gender (Member #2)*

Is Member #2's home address different than the billing address?*

Yes

No

Home Address (Member #2 - if different from billing address)*

Street Address Address Line 2 City State ZIP Code

Digital Signature (Member #2)*

Please type your initials to confirm this agreement.

Payment Schedule*

I will pay annually. 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 while this Agreement remains in effect.

I will pay semiannually. I understand one-half of the annual fee will be charged upon receipt of this form and one-half will be charged automatically at six-month intervals, continually while this Agreement remains in effect.

ACH (Electronic Bank Transfer): Payment has been temporarily disabled.

Consent (Choose One)*

Credit Card: I authorize Company to automatically charge my credit card the amount(s) indicated on this form.

Credit Card Type*

VISA

MasterCard

AMEX

Discover

Card Number*

Expiration Date*

Security Code*

Cardholder Name*

Consent*

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

Billing Address*

Street Address Address Line 2 City State ZIP Code

Daytime Phone Number*

How did you hear about our practice?*

Bank Name*

Routing Number*

Please Confirm Your Routing Number*

Account Number*

Please Confirm Your Account Number*

Consent*

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

Billing Address*

Street Address Address Line 2 City State ZIP Code

Daytime Phone Number*

How did you hear about our practice?*

Please let us know how you heard about your practice:*

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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:

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Lown Cardiology Group
830 Boylston Street, Suite 205
Chestnut Hill, MA 02467

Membership Agreement

Boston Heart, LLC, dba Lown Cardiology Group

Member #1

Member #2