Step 2 of 4

Signature enrollment forms

Complete required forms before payment.

Please select or confirm the membership level below, then open and complete each required form before continuing to Stripe payment.

Patient contact & enrollment information

Selected membership level

Payment preference

Primary patient full legal name

Date of birth

Phone

Street address

City

State / ZIP

Emergency contact

Emergency contact phone

Step 2

Membership Enrollment Forms & Signature

These forms establish your membership, consent, privacy acknowledgments, and practice policies. Your clinical health history forms will be sent separately through our Tebra clinical site after your appointment is scheduled.

Membership agreement

Membership Agreement

I am enrolling with Hello Wellness Primary Care according to the membership level selected during enrollment. I understand that membership provides access to the services described by the selected plan and does not replace emergency care, hospital care, specialist care, or services outside the membership scope.

Current membership levels: Platinum Membership, Gold Membership, Bronze Membership, Family Plan, and Fee-Per-Visit Plan. Family Plans provide a discounted rate for additional family members living in the same household. Seasonal membership, when selected for eligible membership levels, is limited to a 6-month membership term.

I understand my selected membership level, included visit structure, and any limits or terms associated with that selection. I understand Hello Wellness Primary Care is not an emergency service. For a medical emergency, I should call 911 or go to the nearest emergency department. I understand outside labs, imaging, prescriptions, specialist care, hospital care, and services not specifically included in my plan may be billed separately by outside entities or may require separate payment. If I selected a Seasonal Member option, I understand my membership term and payment summary are calculated for 6 months.

Patient / responsible party signature

Date

Financial policy and private-pay acknowledgment

Financial Policy

Payment is due according to the selected membership or visit-based plan. Membership fees are collected directly by Hello Wellness Primary Care and are not billed to insurance.

I understand Hello Wellness Primary Care does not bill insurance for membership services, and I am responsible for membership fees, enrollment fees when applicable, and visit-based fees when applicable. I understand outside services, including labs, imaging, medications, emergency care, hospital services, and specialist services, may be billed separately and are not guaranteed to be covered by membership. I understand missed or failed payments may delay or suspend non-urgent membership services until the account is brought current. I understand HSA/FSA reimbursement eligibility is not guaranteed and depends on my individual plan rules.

Financial policy signature

Date

Cancellation, communication, and household policy

Practice Policies

These policies help protect scheduling access and quality time for each patient.

I understand appointments cancelled with less than 12 hours notice or missed without notice may be subject to a cancellation or no-show fee. I consent to being contacted for enrollment, scheduling, billing, and care coordination using the phone number and email I provide. It is okay to leave a limited voicemail or message related to scheduling, enrollment, or care coordination unless I notify the practice otherwise. For Family Plan enrollment, I understand discounted additional-family-member pricing applies to family members living in the same household.

Communication notes or restrictions

Practice policy signature

Date

Consent to treat

Consent to Treat

I voluntarily consent to evaluation, diagnosis, treatment, health counseling, care coordination, medication review, and related primary care services provided by Hello Wellness Primary Care within the provider’s clinical scope.

I consent to receive care from Hello Wellness Primary Care. I understand medicine is not an exact science and no guarantee has been made about outcomes. I understand I may be referred to urgent care, emergency care, specialty care, imaging, labs, or another clinician when clinically appropriate.

Consent to treat signature

Date

Telehealth consent

Telehealth Consent

Telehealth may be available for established patients when clinically appropriate. Telehealth may include secure video, telephone, messaging, or electronic communication.

I consent to telehealth services when clinically appropriate. I understand telehealth has limitations compared with in-person evaluation and may not be appropriate for all concerns. I understand I may be directed to in-person care, urgent care, emergency care, labs, or imaging based on clinical need. I understand technical or privacy risks may exist even when reasonable safeguards are used.

Telehealth consent signature

Date

HIPAA privacy acknowledgment

HIPAA / Privacy Acknowledgment

I acknowledge that I have received or been offered access to the Notice of Privacy Practices and understand that my protected health information may be used or disclosed for treatment, payment, and healthcare operations as allowed by law.

I acknowledge receipt of or access to the Notice of Privacy Practices. I understand my information may be used for treatment, payment, healthcare operations, scheduling, enrollment, and care coordination. I consent to reasonable electronic communication for enrollment, scheduling, and care coordination.

Preferred communication

Okay to text?

Okay to email?

HIPAA acknowledgment signature

Date

Nondiscrimination and accessibility acknowledgment

Nondiscrimination and Accessibility Policy

Hello Wellness Primary Care is committed to providing respectful, accessible care. We follow applicable federal civil rights laws and do not exclude, deny care to, or treat patients differently because of race, color, national origin, age, disability, sex, or other protected status under applicable law.

Communication assistance: Patients who need help communicating with our practice may request reasonable aids or services, such as accessible written materials or interpretation support when available and appropriate. Patients whose primary language is not English may request language assistance so they can better understand care instructions, forms, and practice communication.

I acknowledge that Hello Wellness Primary Care does not discriminate on the basis of race, color, national origin, age, disability, sex, or other protected status under applicable law. I understand I may contact the practice if I need reasonable communication assistance, accessible materials, or language support related to my care or enrollment. I understand that if I believe I have experienced discrimination or have not received appropriate communication assistance, I may contact Hello Wellness Primary Care using the contact information listed on the website to request help or file a concern.

Requested assistance or accommodation, if any

Preferred contact method

Nondiscrimination policy acknowledgment signature

Date

Payment authorization

Payment Authorization

I authorize payment according to the selected plan and payment preference. Payment will be completed through Stripe on the next page.

Cardholder name

Billing ZIP

Card type

Last 4 digits only

I authorize Hello Wellness Primary Care to charge the payment method I provide through Stripe for the selected membership, enrollment fee when applicable, visit-based fees when applicable, and authorized recurring payments. I understand recurring memberships may continue until cancelled according to the practice policy. I understand payment card details should be entered only through the secure Stripe checkout page, not emailed or typed into open text fields.

Payment authorization signature

Date

Minor / guardian authorization

Minor Patient or Responsible Party

Complete this section when the patient is under 18 or when a responsible party is signing for another enrolled family member.

Parent / guardian / responsible party name

Relationship to patient

Responsible party phone

Responsible party email

I confirm I have legal authority to consent to care and financial responsibility for the patient listed above, when applicable.

Guardian / responsible party signature

Date

Final enrollment signature

Final Signature

By typing my name below, I confirm that I reviewed and completed the forms above and that the information I provided is accurate to the best of my knowledge.

Final electronic signature

Date signed

Optional notes for Hello Wellness

Before publishing, connect this page to your preferred secure e-signature or HIPAA-compliant form capture workflow. This HTML version provides the full fillable form layout and patient-facing language for WordPress.

Membership agreementFinancial policyConsent to treatTelehealth consentHIPAA acknowledgmentPayment authorization

Continue to Payment Schedule Appointment

Signature page checklist

Patient and enrollment information
Membership agreement
Financial policy and no-insurance/private-pay acknowledgment
Cancellation, communication, and household policy
Consent to treat
Telehealth consent
HIPAA privacy acknowledgment
Nondiscrimination and accessibility acknowledgment
Payment authorization
Minor/guardian authorization when applicable
Final electronic signature before Stripe payment

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