A.L.M.S. CHC Clinic Membership
Clinic Membership Information
ALMS Community Health Center, Inc., Membership Plan:
A.L.M.S. Representative:___________________________________________________________________Date:________________________________________
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For families signing up with children under 18 years of age, please print the child/children name(s) and sign below:
Parent Signature:__________________________________________________________________________Date:________________________________________
Child 1 ____________________________________________________. Child 5 _______________________________________________________
Child 2 ____________________________________________________. Child 6 _______________________________________________________
Child 3 ____________________________________________________. Child 7 _______________________________________________________
Child 4 ____________________________________________________. Child 8 _______________________________________________________
This page is for informational purposes only. Applications for A.LM.S. CHC membership can only be completed in person in the office. All applications must be signed by one of A.L.M.S. representatives to be valid. We look forward to serving your health care needs. A.L.M.S. CHC reserves the rights to update fees and payments on all services and membership dues at anytime without prior consent.
- Family membership cost: $149.99 monthly for up to a family of 5 and 199.99 for a family of 6 or more (Please call for more information at 214~862~5756 and ask to speak to our Office Manager and she will be glad to assist). if the family includes more than 5, then the fee will be assigned at a rate of $35 for each additional child. Must be able to provide proof of guardianship for all children when asked.
- Individual membership cost: $30.00 monthly for all ages until December 31, 2020 for the initial introductory offer. Starting January 1, 2021 the membership dues will increase to $60.00 per person and $149.99 monthly for a family of 5 and $199.99 for a family of 6 or more. All members who joined during the initial introductory offer in 2020 will remain on the introductory offer until June 2021. (Membership fees are subject to change on an annual basis).
- A.L.M.S. CHC membership 'Yearly Wellness exams' are $250.00 (Include Well Women's Health and Men's Health exam).
- Pediatric annual 'Wellness exams' $65.00
- Out of pocket maximum per visit up to $105 for full set of labs in office (Specialty Labs at an additional cost).
- No waiting periods for membership usage.
- No exclusions for pre-existing conditions.
- Any privately funded vaccines will be charged at a preassigned rate for all childhood vaccines. We will no longer be providing vaccines for children 4 years of age and under. In the future we will be providing vaccines and immunizations through the Vaccine for Children (VFC) program for children ages 18 and under as part of their membership (Only when vaccines are available). At this time vaccines are not available through the Vaccine for Children (VFC) program through A.L.M.S. Community Health Center. We will keep you updated when these vaccines become available.
- Adult Vaccinations (not included in clinic membership plan)
- MRI, CT’s, Mammography, Ultrasonography, Sleep studies, Hearing screening, vision screening, spirometry testing,
- These special procedures: X-rays, CT’s, MRI’s, X-rays, ultrasonography, sleep studies, and Mammograms shall be performed at an off-site imaging and sleep center (fees are a separate charge based on the off-site testing centers).
- Cardiology recommendation upon referral:
- Cardiac Nuclear stress test, and treadmill stress tests via a cardiology consult.
- Optional cardiovascular wellness checks (EKG's in Office) once a year (annually). Special pricing available upon request with patients under the care of their Primary care provider with referrals when necessary to a cardiologist.
- Cardiology referral visits (This fee is not included in your clinic membership plan but is discussed with the cardiology consult before the initial visit scheduled)
- Associated cost for the initial visit predetermined by the cardiologist. This may be an offsite visit in most cases.
- Co-pays are associated with each additional visit by the cardiologist for follow up visits (these must be prearranged after the initial visit with the cardiologist)
- A.L.M.S. CHC membership agreement information:
- Individuals may acquire a 1 year membership with a month to month membership as follows:
- An individual obtaining an annual membership agreement is approved for 12 visits per year, at anytime during that year.
- Clinic membership co-pay cost is $25.00 per/visit for adults only. No copay for children enrolled in the clinic membership plan ages 17 and under.
- On the 13th and subsequent visits in the same year, the co-pay increases to $40.00 per/visit.
- A.L.M.S. CHC membership benefits are applicable during the individual’s membership year (some prescribed special procedures can be discounted by the imaging/health partners at a predetermined amount).
- Full monthly membership dues are due by the 1st (first) and/or the 15th (fifteenth) each month for the above membership benefits to apply on that month’s visit(s).
- If the membership fee lapses, the member is NOT eligible for the above membership benefits on that month, and standard A.L.M.S. CHC fees will apply on ALL provider services.
- The membership may be renewed on the 1st (first) of the following month, and at that time full membership benefits will apply.
- Individuals may cancel their A.L.M.S. CHC membership in writing 30 days in advance by submitting a written notice signed and dated by the member and mailed or dropped off at 2100 Virginia Street, Suite - F, Grand Prairie, Texas 75051.
- There is an initial A.L.M.S. CHC membership of 6 months required before the cancellation can be accepted.
- The initial membership fee paid by credit or debit will be for the first 2 months of membership. This payment is a non-refundable payment required at sign up for each individual or group membership.
- A.L.M.S. CHC membership plan is not an insurance plan but a membership plan to benefit the uninsured and under-insured patient, A.L.M.S. CHC memberships are accepted only at A.L.M.S. CHC participating locations.
- Individuals may acquire a 1 year membership with a month to month membership as follows:
- All copays associated with insurances companies are due at the time of the visit.
A.L.M.S. Representative:___________________________________________________________________Date:________________________________________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
For families signing up with children under 18 years of age, please print the child/children name(s) and sign below:
Parent Signature:__________________________________________________________________________Date:________________________________________
Child 1 ____________________________________________________. Child 5 _______________________________________________________
Child 2 ____________________________________________________. Child 6 _______________________________________________________
Child 3 ____________________________________________________. Child 7 _______________________________________________________
Child 4 ____________________________________________________. Child 8 _______________________________________________________
This page is for informational purposes only. Applications for A.LM.S. CHC membership can only be completed in person in the office. All applications must be signed by one of A.L.M.S. representatives to be valid. We look forward to serving your health care needs. A.L.M.S. CHC reserves the rights to update fees and payments on all services and membership dues at anytime without prior consent.
