EMC - Membership Agreement

Executive Medical Consultants (EMC)
526 Canton Road, Suite 212, Akron, OH 44312
Phone: 330-794-1200 / Fax: 330-315-2554
www.EMCwins.com

EMC Membership Agreement

To enroll for EMC Solution Services, please complete the information below to establish a record for you and your family dependents. This begins the process to obtain customer services for medical bill management and resolution assistance. Please print and complete in full. Your information is kept private and confidential.

Required fields are designated with an *

* First Name:

* Last Name:

* Date of Birth:

* Marital Status:

Maried Single Divorced Widowed

Spouse Name:

Date of Birth:

Children's Name	Gender	DOB	Medical Care Provider (Insurance Company)
	Male Female
	Male Female
	Male Female
	Male Female

* Address:

* City:

* State:

* Zip:

* Home Phone:

* Email Address:

* Work Phone:

Employer:

* Have you served in the U.S. Military?:

Yes No

Branch?:

* How did you hear about EMC? :

Annual EMC Solution Services Memberships are selected for Individuals and Families as identified below.

We provide one type of annual membership - a membership for yourself, your family members are free of charge. You may also choose to purchase a gift certificate for another Individual or Family. In this case, we will contract them to obtain their Membership information and inform them about the services EMC provides.

* Membership Type:
$249 - EMC Membership is for the owner and his or her family. This includes the EMC Member and the members of his or her immediate family: The member, member's spouse, and all unmarried dependent children covered on the member's insurance policy. This also includes any applicable discounts.

Annual EMC Memberships are payable upon signing this agreement. All annual membership renewals will require updated information and signed with payment one year from activation date. As a member you will receive notification for annual renewals, unless we have received a 30-day cancellation letter. Thank you!