Membership AgreementFrekko Primary CareOnline Enrollment with Credit Card Only I have engaged Frekko Personalized Care, LLC (Frekko), to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning on December 22, 2024. I understand that this Agreement will renew automatically following the end of each one-year period unless I provide Frekko 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 December 22, 2024 as well as every one-year renewal period thereafter. FOR PATIENT MEMBERSHIP DURING THE SERVICE YEAR, I AGREE TO PAY FREKKO PERSONALIZED CARE, LLC:* ❑ $2,250/year = Individual ❑ $4,050/year = Couple Dependents (Optional):*Dependent children ages 18 up to 26 $500/year = Each dependent child when parent is a member. You will be asked to list Name(s) and Date(s) of Birth for each Dependent.No DependentsOne (1) DependentTwo (2) DependentsThree (3) Dependents (+$500 / Annually)Four (4) Dependents (+$1,000 / Annually)Five (5) Dependents (+$1,500 / Annually)Total (Annually): $0.00 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 will 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 Frekko 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 Frekko otherwise (or Frekko notifies me) within 30 days of the next payment due date. Member #1Name (Member #1)* First Last Select Provider (Member #1)* Dr. Kathleen Farrell Dr. Ann Raffo No Preference 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)* MM slash DD slash YYYY Gender (Member #1)*Please Select a GenderMaleFemaleIs 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Digital Signature (Member #1)*Please type your initials to confirm this agreement. Member #2Name (Member #2)* First Last Select Provider (Member #2)* Dr. Kathleen Farrell Dr. Ann Raffo No Preference Email (Member #2) - OPTIONAL Mobile Phone Number (Member #2)Date of Birth (Member #2)* MM slash DD slash YYYY Gender (Member #2)*Please Select a GenderMaleFemaleIs 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Digital Signature (Member #2)*Please type your initials to confirm this agreement. Dependent #1Name (Dependent #1)* First Last Select Provider (Dependent #1)* Dr. Kathleen Farrell Dr. Ann Raffo No Preference Date of Birth (Dependent #1)* MM slash DD slash YYYY Gender (Dependent #1)*Please Select a GenderMaleFemaleEmail (Dependent #1) - OPTIONAL Dependent #2Name (Dependent #2)* First Last Select Provider (Dependent #2)* Dr. Kathleen Farrell Dr. Ann Raffo No Preference Date of Birth (Dependent #2)* MM slash DD slash YYYY Gender (Dependent #2)*Please Select a GenderMaleFemaleEmail (Dependent #2) - OPTIONAL Dependent #3Name (Dependent #3)* First Last Select Provider (Dependent #3)* Dr. Kathleen Farrell Dr. Ann Raffo No Preference Date of Birth (Dependent #3)* MM slash DD slash YYYY Gender (Dependent #3)*Please Select a GenderMaleFemaleEmail (Dependent #3) - OPTIONAL Dependent #4Name (Dependent #4)* First Last Select Provider (Dependent #4)* Dr. Kathleen Farrell Dr. Ann Raffo No Preference Date of Birth (Dependent #4)* MM slash DD slash YYYY Gender (Dependent #4)*Please Select a GenderMaleFemaleEmail (Dependent #4) - OPTIONAL Dependent #5Name (Dependent #5)* First Last Select Provider (Dependent #5)* Dr. Kathleen Farrell Dr. Ann Raffo No Preference Date of Birth (Dependent #5)* MM slash DD slash YYYY Gender (Dependent #5)*Please Select a GenderMaleFemaleEmail (Dependent #5) - OPTIONAL Payment Schedule* I will pay annually. I understand that 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 automatically at six-month intervals, continually while this Agreement remains in effect. I will pay quarterly. I understand one-quarter of the annual fee will be charged automatically at three-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 Frekko Personalized Care, LLC. to automatically charge my credit card the amount(s) indicated on this form. ACH (Electronic Bank Transfer): I authorize the Frekko Personalized Care, LLC. to automatically pull from my bank account via ACH the amount(s) indicated on this form. Credit Card Type* VISA MasterCard AMEX Discover Card Number* Card Number* Expiration Date* Security Code* Security Code* Cardholder Name* Consent* I authorize Frekko Personalized Care, LLC. to automatically charge my credit card the amount(s) indicated on this form. Billing Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Daytime Phone Number*How did you hear about our practice?*I am a Current PatientI am a Former PatientInsurance ProviderInternet SearchPatient ReferralPhysician ReferralPrint AdvertisingOther Bank Name* Routing Number* Please Confirm Your Routing Number* Account Number* Please Confirm Your Account Number* Consent* I authorize Frekko Personalized Care, LLC. to automatically pull from my bank account the amount(s) indicated on this form. Billing Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Daytime Phone Number*How did you hear about our practice?*I am a Current PatientI am a Former PatientInsurance ProviderInternet SearchPatient ReferralPhysician ReferralPrint AdvertisingOtherPlease let us know how you heard about your practice:* {all_fields}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:Your QUARTERLY Payment:This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged QUARTERLY:CAPTCHAShipping Δ I have engaged Frekko Personalized Care, LLC (Frekko), to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning on December 22, 2024. I understand that this Agreement will renew automatically following the end of each one-year period unless I provide Frekko 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 December 22, 2024 as well as every one-year renewal period thereafter. FOR PATIENT MEMBERSHIP DURING THE SERVICE YEAR, I AGREE TO PAY FREKKO PERSONALIZED CARE, LLC:* ❑ $2,250/year = Individual ❑ $4,050/year = Couple Dependents (Optional):*Dependent children ages 18 up to 26 $500/year = Each dependent child when parent is a member. You will be asked to list Name(s) and Date(s) of Birth for each Dependent.No DependentsOne (1) DependentTwo (2) DependentsThree (3) Dependents (+$500 / Annually)Four (4) Dependents (+$1,000 / Annually)Five (5) Dependents (+$1,500 / Annually)Total (Annually): $0.00 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 will 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 Frekko 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 Frekko otherwise (or Frekko notifies me) within 30 days of the next payment due date. Member #1Name (Member #1)* First Last Select Provider (Member #1)* Dr. Kathleen Farrell Dr. Ann Raffo No Preference 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)* MM slash DD slash YYYY Gender (Member #1)*Please Select a GenderMaleFemaleIs 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Digital Signature (Member #1)*Please type your initials to confirm this agreement. Member #2Name (Member #2)* First Last Select Provider (Member #2)* Dr. Kathleen Farrell Dr. Ann Raffo No Preference Email (Member #2) - OPTIONAL Mobile Phone Number (Member #2)Date of Birth (Member #2)* MM slash DD slash YYYY Gender (Member #2)*Please Select a GenderMaleFemaleIs 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Digital Signature (Member #2)*Please type your initials to confirm this agreement. Dependent #1Name (Dependent #1)* First Last Select Provider (Dependent #1)* Dr. Kathleen Farrell Dr. Ann Raffo No Preference Date of Birth (Dependent #1)* MM slash DD slash YYYY Gender (Dependent #1)*Please Select a GenderMaleFemaleEmail (Dependent #1) - OPTIONAL Dependent #2Name (Dependent #2)* First Last Select Provider (Dependent #2)* Dr. Kathleen Farrell Dr. Ann Raffo No Preference Date of Birth (Dependent #2)* MM slash DD slash YYYY Gender (Dependent #2)*Please Select a GenderMaleFemaleEmail (Dependent #2) - OPTIONAL Dependent #3Name (Dependent #3)* First Last Select Provider (Dependent #3)* Dr. Kathleen Farrell Dr. Ann Raffo No Preference Date of Birth (Dependent #3)* MM slash DD slash YYYY Gender (Dependent #3)*Please Select a GenderMaleFemaleEmail (Dependent #3) - OPTIONAL Dependent #4Name (Dependent #4)* First Last Select Provider (Dependent #4)* Dr. Kathleen Farrell Dr. Ann Raffo No Preference Date of Birth (Dependent #4)* MM slash DD slash YYYY Gender (Dependent #4)*Please Select a GenderMaleFemaleEmail (Dependent #4) - OPTIONAL Dependent #5Name (Dependent #5)* First Last Select Provider (Dependent #5)* Dr. Kathleen Farrell Dr. Ann Raffo No Preference Date of Birth (Dependent #5)* MM slash DD slash YYYY Gender (Dependent #5)*Please Select a GenderMaleFemaleEmail (Dependent #5) - OPTIONAL Payment Schedule* I will pay annually. I understand that 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 automatically at six-month intervals, continually while this Agreement remains in effect. I will pay quarterly. I understand one-quarter of the annual fee will be charged automatically at three-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 Frekko Personalized Care, LLC. to automatically charge my credit card the amount(s) indicated on this form. ACH (Electronic Bank Transfer): I authorize the Frekko Personalized Care, LLC. to automatically pull from my bank account via ACH the amount(s) indicated on this form. Credit Card Type* VISA MasterCard AMEX Discover Card Number* Card Number* Expiration Date* Security Code* Security Code* Cardholder Name* Consent* I authorize Frekko Personalized Care, LLC. to automatically charge my credit card the amount(s) indicated on this form. Billing Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Daytime Phone Number*How did you hear about our practice?*I am a Current PatientI am a Former PatientInsurance ProviderInternet SearchPatient ReferralPhysician ReferralPrint AdvertisingOther Bank Name* Routing Number* Please Confirm Your Routing Number* Account Number* Please Confirm Your Account Number* Consent* I authorize Frekko Personalized Care, LLC. to automatically pull from my bank account the amount(s) indicated on this form. Billing Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Daytime Phone Number*How did you hear about our practice?*I am a Current PatientI am a Former PatientInsurance ProviderInternet SearchPatient ReferralPhysician ReferralPrint AdvertisingOtherPlease let us know how you heard about your practice:* {all_fields}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:Your QUARTERLY Payment:This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged QUARTERLY:CAPTCHAShipping Δ If you have further questions, please call our Patient Information Line at 301-337-7900. We will be happy to assist you.
