Lown Group

Membership Agreement

Boston Heart, LLC, dba Lown Cardiology Group,

If you have questions, please call my membership team Specialdocs Consultants at (678) 813-1155.

Online Enrollment with Credit Card Payment Only

"*" indicates required fields

Step 1 of 5

20%

I have engaged Boston Heart, LLC, dba Lown Cardiology Group (Company) and its physicians to provide non-covered, non-clinical amenities and benefits to me/us for an initial minimum period of one year beginning on my/our Start Date, 4/1/2025 . I/we understand that this Agreement will renew automatically following the end of each one-year period unless I/we provide Company a written notice of non-renewal. I/we further understand that I/we will be required to pay the yearly membership fee for the non-covered services, amenities and benefits for a minimum of one year. As used in this Agreement, the term “Start Date” refers to the one-year period beginning on the date of enrollment, as well as every one-year renewal period thereafter.I/we understand that the first payment of my/our annual fee will be charged upon enrollment and the balance will be charged according to my/our terms selected after the Start Date, continuously, while this Agreement remains in effect

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

$6,000/year = Internal Medicine for existing patient of Dr. Mahrokhian or Dr. Simeone

$10,000/year = Internal Medicine for new patient

Total (Annually):

This Agreement is for non-covered, non-clinical amenities and benefits as described in the Highlights & Details document. I/we have read and understand this Agreement as well as the Highlights & Details and Frequently Asked Questions documents that are considered a part of this Agreement. Unless the Agreement is terminated as provided in the first paragraph above, it will automatically renew for subsequent Service Years under the same payment terms unless I/we notify Company otherwise (or Company notifies me/us) within 30 days prior to the next payment due date. Concierge membership fees are subject to change. I/we authorize my/our physician(s) and/or their billing company to send emails regarding my/our membership, enrollment, invoices, upcoming and past due payments, and receipts.

Member #1

Name (Member #1)*

First Last

Select Provider (Member #1)*

Dr. Lilian Mahrokhian, MD

Dr. Harley Simeone, MD

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)*

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

Yes

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. Lilian Mahrokhian, MD

Dr. Harley Simeone, MD

Email (Member #2) – OPTIONAL

Mobile Phone Number (Member #2)

Date of Birth (Member #2)*

MM slash DD slash YYYY

Gender (Member #2)*

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

Yes

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 enrollment of this form and the full annual fee will be charged automatically at 12-month intervals from my Start Date, continually while this Agreement remains in effect.

I will pay semiannually.I understand one-half of the annual fee will be charged upon enrollment of this form and one-half will be charged automatically at six-month intervals from my Start Date, 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: