Complete Care Center

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Address		Address 2
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Phone		Cellphone
Birth Date	Click Calendar

Your Plan
A Non-Refundable One Time Processing Fee of $30 will be Added to Your Selected Plan

Individual $35/mo	Save 10% with Yearly Payment of $378
Couple $35/mo	Save 10% with Yearly Payment of $756
Family Plan	Save 10% with Yearly Payment of $1350
Three Family Members - $105 Per Month Four Family Members - $125 Per Month Additonal Family Members - $15 Per Month Each Please Select Total Number of Family Members You Wish to Enroll

I would like to save 10% - please process my plan as an annual payment

Your Membership Benefits Become Active 7 Days from Todays Date:
08/26/2008 22:08:19

Membership Terms

I Agree To These Terms
I agree to notify Complete Care Center in writing of any changes in my account information or termination of this authorization 15 days prior to the next due date of the charges. I understand that cancellations must be made in writing. Member authorizes Complete Care Center to debit the account for all sums owing to Complete Care Center including but not limited to administration fees, late fees, or any other delinquent amount and all taxes enacted by the state of Michigan or any governing authority. If auto payment is interrupted and non obtainable for any reason the member’s membership benefits are immediately cancelled on the monthly or annual renewal date which ever applies. Membership: This membership is not transferable and member may not sell, assign or transfer this agreement, his/her membership card or membership in Care Card or any other right or privilege and any such attempted sale, assignment or transfer shall be null and void. Member may not loan his/her membership card to anyone.

Auto-Recurring Payment Authorization Form

I Agree To These Terms

This is an authorization to automatically renew your thirty day membership on a month to month basis which becomes effective on the seventh (7 th ) day from your join date. Member agrees to give fifteen (15) days written notice of cancellation effective after the seventh (7 th ) day from join date has been completed. Member acknowledges that he/she is liable for all fees and bank charges related to member’s Care Card Membership transactions. I authorize Complete Care Center to charge/debit my account on the date of this application a one time only payment in the amount of the initial Processing Fee and first month payment of my Care Card Membership™ and then monthly recurring payments for the second month and thereafter of on the same day of each month for the entire duration of membership.

Insurance Statement

I Agree To These Terms

I hereby fully inform Complete Care Center that I do not have insurance or have insurance that Complete Care Center does not participate with. I am responsible for full payment of “Time Of Service” fees at the time of service. I also release Complete Care Center from any billing issues in the future with insurance companies or others concerning “TOS” charges. “I have read and understand and agree with the this statement.”