Family Member Discount Form

If you have family members who are also patients of Mercy Doctors Medical Group, you may be entitled to a discount on your Annual Practice Fee. After the primary patient has paid the full $250 fee, each subsequent family member living at the same address and under the same insurance policy will be eligible for a reduced Annual Practice Fee rate of only $150 per eligible family member.

To submit a request for the Family Member Discount, please fill out the secure form below:

Signing up is easy! You can fill out the form below online or print and complete the paper Family Member Discount application HERE and submit it in one of the following ways:

Fax to (415) 651-8857
Email to billing_mdmgsf@protonmail.com
Mail to:
Mercy Doctors Medical Group
One Shrader Street, Suite 640
San Francisco, CA 94117
Drop off your completed form at the Mercy Doctors Medical Group office.

Name

First Name

Last Name

Email

Today's date

MM

DD

YYYY

Primary Patient full name, including middle initial if applicable

Patient paying the full $250 fee

Requesting Patient (s) full name(s) and middle initial if applicable (Please specify relationship to primary patient)

This is the patient who will pay $150 after the discount. List all who apply and their specific relationship to the primary patient (e.g., spouse, daughter, etc.).

I am requesting a Family Member Discount. I am the spouse or dependent of a full, fee-paying patient under the same insurance policy. Please provide the names of the primary family member and each family/household member requesting this discount. The primary patient will be responsible for the full fee. Each subsequent family member under the same insurance policy will be eligible for a reduced Annual Practice Fee rate of $150 per eligible family member ($100 discount). I understand that the $25 email/credit card discount applies only to the primary patient and not the subsequent family members.

I understand