PERSONAL MD CANCELLATION FORM
Personal MD Family Healthcare, P.A. programs are designed as a month-to-month payment model. As a reminder, your contract requires a 30 day notice when terminating. As detailed in the original membership contract, the active members listed will be able to utilize Personal MD Family Healthcare, P.A. and its services until the final date the contract is active.
After your contract is terminated, Personal MD and its providers will no longer provide any form of medical care services for any member listed on the contract unless the member initiates a new contract and pays the appropriate fees. You are also acknowledging that you understand Personal MD Family Healthcare, P.A. maintains the right to change our membership programs, services provided, and cost of services without notifying you or any contracted member. If you initiate a new contract with Personal MD Family Healthcare, P.A., you will be subject to the new cost structure and the included services of our active programs.
If you decide to cancel your termination, you must provide a written notice to our office and have it signed by a Personal MD executive member. Thank you for putting your trust in Personal MD and its staff members.
Name of person canceling Personal MD memberhship
To cancel membership, read and agree to the "Termination Agreement" above
I am authorized to make changes to my contract with Personal MD Family Healthcare, P.A.
I am Authorized
IMPORTANT: Confirmation of Contract Cancellation will be sent to this Email account.
Cancel entire contract
Cancel specific members from contract
List the name(s) of the member(s) to be terminated:
Do Not Fill This Out