Charter Internal Medicine Retainer Fee Agreement

							                              Charter Internal Medicine
                                    Personal Health Care Medicine

                                      Retainer Fee Agreement
Once your Retainer Fee Agreement and fee have been received, you will be notified that you have been accepted into
your physician’s practice. In the event your physician’s practice is full, you may place your name on a waiting list.
Alternately, you may be able to transition to an associate’s practice on a space-available basis. Please complete the
information below:

Your name: ___________________________________________ Date of Birth: _________________

Your physician’s name: __________________________________

Name(s) of any children (ages 14 – 25) to be included: _______________________________________

Have they already been seen? Y or N (circle one). If so, by which physician: ____________________

Your email address: __________________________________

Daytime telephone number: ____________________________

Please indicate your preferred schedule of payment:
□   Paid annually, in full: one payment of $2,000 plus $500 for each child ages 14 – 25

□   Paid semi-annually: initial payment of $1,050 plus $500 for each child ages 14 - 25;
    second payment of $1,050 due in 6 months. You will be invoiced for your second payment.

Please indicate your preferred method of payment:
□   Personal check, made payable to your physician (please circle):
           Harry A. Oken, MD
           Jonathan S. Fish, MD
           Kevin E. Carlson, MD
           Randal P. Riesett, MD
           Michael C. Albert, MD

□   Credit Card (circle one: Visa    MasterCard    Discover    American Express)

    Card Number: ____________________________________________________

    Expiration Date: ___________________          Security Code: _______________

ATTN Flexible Spending or Health Savings Account Users: (please check box if appropriate)
□   If your plan requires your Retainer Fee payment be dated in 2009, you may make your payment on January 1,
2009. To reserve your space, a $500 deposit is required; this must be in the form of a check (made payable as above)
which will be held and returned to you upon payment from your HSA or FSA.

Return your completed form and payment by one of the following methods:
□   Mail to:   Charter Internal Medicine, 10700 Charter Drive, Suite 200, Columbia, MD 21044

□   Fax to:    410-910-2310 (credit card payments only)

□   Drop off at the above address

My signature below authorizes my credit card payment and confirms that I am willing to receive unencrypted
emails from Charter Internal Medicine:
    Signature: _________________________________________         Date: _______________________

Medicare patients must complete the reverse side of this page before we can accept your payment!   ►(over)