Please complete this form in its entirety and with accurate and up-to-date information in order to activate your newly purchased Amplifii Health Subscription
Essential = $85
Premium = $105
Comprehensive = $120
Essential = $70
Premium = $85
Comprehensive = $95
$25 for each child
Member Acknowledgments: Please check each of the below boxes, acknowledging each statement.
*I understand that AMPLIFII Health Direct Primary Care is not health insurance.
*I understand that participation in this program covers only the services included in my selected plan tier and does not guarantee coverage for services outside that tier.
*I understand that accessing services not included in my plan may result in additional charges, and I am financially responsible for the additional charges.
*I understand that specialist care, hospital services, emergency care, and other non-included services are not covered by this program unless specifically stated by the program.
*I understand that program fees are due on a recurring basis to maintain active enrollment.
*I understand that program eligibility and access to services may be suspended or terminated if payment is not received according to program terms.
*This is a I understand that it is my responsibility to notify AMPLIFII Health of changes to my contact information, household coverage, or payment information.
*I acknowledge that I have received or been offered information describing membership benefits, limitations, and program terms.