MEMBER PARTICIPATION AGREEMENT KRISTIN ANDRUSKA, MD, PHD, PC If you have questions, please call my membership team Specialdocs at (408) 740-3785. Step 1 of 4 – Agreement Details 25% I have engaged Kristin Andruska, MD, PhD, PC dba the California Movement Disorders Center (Corporation), to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year, beginning on October 1, 2021. I understand that this Agreement will renew automatically following the end of each one-year period unless I provide the Corporation with a written notice of non-renewal at least 30 days before the end of a renewal year. I further understand that I will be required to pay a yearly membership fee at the start of each renewal term for these non-covered services, amenities and benefits. As used in this Agreement, the term “Service Year” refers to the one-year period beginning on October 1, 2021, as well as every one-year renewal period thereafter. $6,000/year = Individual Individuals0123456Individuals Price: $0.00 This Agreement is for non-covered, non-clinical amenities and benefits as described in the CMDC Enrollment Packet. I have read and understand this Agreement as well as the CMDC Enrollment Packet documents that are considered a part of this Agreement. I understand that this Agreement can be terminated upon 30 days’ written notice and that, if the Agreement is terminated, I will receive a prorated refund of the annual fee paid, after the initial three (3) month payment, based on the number of days that have elapsed in the Service Year (which will be determined by the Corporation on a case-by-case basis). Such refund will be paid to me within 30 days after termination. Unless the Agreement is terminated, as provided in the first paragraph of this Agreement above, it will automatically renew for subsequent Service Years under the same payment terms unless I notify the practice otherwise (or the practice notifies me) within 30 days of the next payment due date. 1st IndividualName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail(Required) 2nd IndividualName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail(Required) 3rd IndividualName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail(Required) 4th IndividualName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail(Required) 5th IndividualName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail(Required) 6th IndividualName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail(Required) Payment Methodcredit carddebit cardACH(A 3% transaction fee will be incurred. Total charge is $6,180 per individual)Credit Card transaction fees Price: $0.00 Payment Schedule(Required) I will pay annually I will pay semiannually I will pay quarterly I will pay annually. I understand that the full annual fee will be charged upon receipt of this form and the full annual fee will be charged automatically at 12-month intervals, continually (beginning October 1, 2022) while this Agreement remains in effect.I understand one-half of the annual fee will be charged upon receipt of this form and one-half will be charged automatically at six-month intervals, continually (beginning April 4, 2022) while this Agreement remains in effect.I understand one-quarter of the annual fee will be charged upon receipt of this form and one- quarter will be charged automatically at three-month intervals, continually (on or about January 1, 2022) while this Agreement remains in effect.Your ANNUAL Payment:This is the amount that will be charged to your card or pulled from your bank account upon submission of this form, and will subsequently be charged ANNUALLY:Your SEMIANNUAL Payment:This is the amount that will be charged to your card or pulled from your bank account upon submission of this form, and will subsequently be charged SEMIANNUALLY:Your QUARTERLY Payment:This is the amount that will be charged to your card or pulled from your bank account upon submission of this form, and will subsequently be charged QUARTERLY:Card DetailsYour card will be charged by Kristin Andruska, MD, PHD, PCCard Type(Required) Visa Master Card AMEX Discover Card Number(Required)Card Number(Required)Expiration MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberExpiration Year202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050Security Code(Required)Security Code(Required)Cardholder Name(Required)Billing Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Daytime Phone Number(Required)Consent(Required) I authorize the Corporation, to automatically charge my credit card the amount(s) indicated on this form. ACH OptionBilling Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Daytime Phone Number(Required)Bank Name(Required)Account TypeBusinessPersonalRouting Number(Required)Please Confirm Your Routing Number(Required)Account Number(Required)Please Confirm Your Account Number(Required)Consent(Required) I authorize the Corporation, to automatically pull from my bank account the amount(s) indicated on this form. Digital Signature(Required)Please type your initials to confirm this agreement.Is the home address different from billing address(Required) Yes No Home Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How did you hear about our practice?(Required)I am a Current PatientI am a Former PatientInsurance ProviderInternet SearchPatient ReferralPhysician ReferralPrint AdvertisingOther