Patient Information - ENGLISH

Membership Plan

Medical Office Membership

✔ Same/next-day appointments
✔ Telehealth visits (phone or video)
✔ Annual physical exam
✔ Chronic condition management
✔ Guidance for specialists, labs & imaging with self-pay savings
✔ Unlimited office visits (wellness & sick)

– Important Information & Limitations -

Not Health Insurance: This membership is not health insurance and does not replace or substitute for health insurance coverage.
Services Not Covered: Membership does not include hospital care, hospitalization, emergency services, surgery, advanced imaging (such as MRI or CT scans), or consultations with outside specialists.
Independent Providers: Our office is not affiliated with any hospital or outside healthcare facility.
Outside Services and Referrals: We may provide information about independent specialists, laboratories, and imaging centers offering affordable self-pay options. All outside services are billed separately by the respective providers. Discounts and savings are not guaranteed.
Prescription Assistance: We may assist patients in identifying affordable medication options. Prescription medication costs are not included in the membership fee.
Office Hours: Membership services are available during regular weekday office hours only.
Emergency and Urgent Care: This program is not an emergency or urgent care service. For medical emergencies, call 911 or go to the nearest emergency department.

Membership Eligibility and Insurance Acknowledgment
2027 (not for 2026)

Do you currently have health insurance coverage of any kind? This includes Medicare, Medicaid, Medicare Advantage, Marketplace plans, employer-sponsored insurance, or other private/commercial health insurance.

Thank you for your interest in Dr. Bencomo’s Medical Membership Program.

At this time, enrollment in this membership program is available only to patients who do not have active health insurance coverage.

If you currently have Medicare, Medicaid, Medicare Advantage, Marketplace, employer-sponsored, or other private health insurance, please contact our office for information about the services available to you.

Dr. Bencomo’s Medical Membership Program is not health insurance and does not replace health insurance coverage.

By selecting this option, I understand that this membership is a self-pay program and is not health insurance. I understand that membership fees are separate from any health insurance coverage I may have, and that insurance benefits, billing rules, and applicable restrictions may affect which services I can receive through this program.

I acknowledge that I have read, understood, and agree to the following:

Notice of Privacy. For patients enrolled in the MDTELEME Direct Primary Care membership, the insurance-related payment languagein the HIPAA Notice of Privacy Practices does not apply. Membership paymentsare handled directly and are not submitted to insurance.

Medical Membership Agreement, Consents & Privacy Notice

Payment Plan Selection

1st Member

First NameLast Name

Phone Number

Area CodePhone Number

DOB

Our office does not provide pediatric care and does not see patients under the age of 15.

2nd Member

First NameLast Name

Phone Number

Area CodePhone Number

DOB

Our office does not provide pediatric care and does not see patients under the age of 15.

2nd Member’s Relationship to 1st Member

3rd Member

First NameLast Name

Phone Number

Area CodePhone Number

DOB

Our office does not provide pediatric care and does not see patients under the age of 15.

3rd Member’s Relationship to 1st Member

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Agreement
I agree to enroll in the monthly membership program at the selected level above and authorize automatic payment from the credit card I provide at registration. I authorize MDTELEME to process recurring membership payments from my designated payment method.

Cancelation policy:

This Agreement is month-to-month and automatically renews unless either party provides 30 days’ written notice of termination. Either party may cancel at any time without penalty. Monthly membership fees are automatically charged to the Patient’s authorized payment method through Square Subscriptions. Non-payment may result in termination upon written notice. Applicable refunds will be handled in accordance with Florida law.

IMPORTANT LEGAL DISCLOSURE
This agreement is not health insurance and the practice will not file any claims against the patient's health insurance policy or plan for reimbursement of any health care services covered by this agreement.

Patient Acknowledgment:

By signing below, I acknowledge that I have read, understood, and agree to the terms of this Membership Agreement, including that services are provided only in Florida and during the Practice's regular business hours.

My Subscriptions

Individual Plan($30.00 for each month)

Affordable Primary Care Membership: One flat monthly fee. Unlimited visits. Telehealth included. Simple, personalized, and affordable care.

Couple Membership($55.00 for each month)

Affordable Primary Care Membership: One flat monthly fee. Unlimited visits. Telehealth included. Simple, personalized, and affordable care.

Family Membership($75.00 for each month)

Affordable Primary Care Membership: One flat monthly fee. Unlimited visits. Telehealth included. Simple, personalized, and affordable care.

Tarjeta de crédito

Name

First Name/ Nombre Last Name/ Apellido

Phone

Email

example@example.com

Date

Sign

My Subscriptions*

Tarjeta de crédito

My Subscriptions