ACS Online Sign Up

Use the form below to sign up.

Affordable Care Solutions

1Application

2Bank Draft

3Checkout Summary

4Checkout

Primary Member Information
Effective Date
Payment Date
Are you a current patient?
- Yes
- No
First Name*
M.I.
Last Name*
Date of Birth*
MM slash DD slash YYYY
Gender*
Marital Status*
Address*
City
State*
Zipcode*
Primary Phone*
Secondary Phone
Email Address*
SSN
May we send you regular updates via email?
- Yes
- No
Additional Members
Do you wish to add additional member(s)*
- Yes
- No
Additional Member(s)*
First Name* M.I. Last Name* Relationship* DOB* Gender* SSN
Emergency Contact
Name*
Relationship*
Phone*
Terms and Conditions
Please read the terms and conditions of the Affordable Care Solutions membership program and indicate your agreement and approval.
TERMS AND CONDITIONS
1. MEMBERSHIP IS NOT AN INSURANCE POLICY:
  1. Individual understands that they are purchasing a membership to an identified group in order to receive access to a discounted rate plan for medical services.
  2. That discounted rate plan is being offered by the Family Medical Walk-In Clinics, Inc. network of clinics and covers services provided only at their clinic locations.
  3. Member understands that this is NOT an insurance plan.
  4. Member should not consider it to be an insurance plan or use it as a substitute for an insurance plan.
2. DEFINITIONS:
  1. Membership: For the purpose of these “Terms and Conditions” Membership is defined as an agreement entered into voluntarily by all parties. Terms of Membership provide that for an established monthly rate the Member receives standard medical care as then provided in the normal course of business by Family Medical Walk-In Clinics, Inc. at a pre-established discounted rate.
  2. Member: The term which identifies the individual who pays Dues and is provided with a Membership to the Family Medical Walk-In Clinics, Inc. “Affordable Care Solutions” Membership Program.
  3. Minor: Will have the same meaning as that established by the State of Missouri.
  4. Dues: The monthly rate charged by Family Medical Walk-In Clinics, Inc. for inclusion in the “Affordable Care Solutions” Membership Program.
  5. Family Member: Immediate family members living in the home of the Member (husband, wife, children and stepchildren).
  6. Provider: Physician, Nurse Practitioner, and Physician Assistant
3. MEMBERSHIP RESTRICTIONS:
  1. A Member’s privileges are subject to their having no outstanding amounts due to Family Medical Walk-In Clinics, Inc.
  2. Member must present a current Membership card or picture ID in order to receive Membership benefits.
  3. Members must pay their first two months up front of Membership Dues upon registration.
  4. Dues will be charged and deducted on a prospective monthly basis.
  5. Minors may not be seen by staff without a parent or legal guardian being present or as allowed by Missouri law.
  6. One free Membership card will be issued per Member. Replacement cards may be acquired for a fee as set by Family Medical Walk-In Clinics, Inc.
  7. Membership rates and hours of use are subject to change without notice.
  8. Membership is non-transferable.
  9. Since the medical services included in Membership are “covered services” persons with Medicare or Medicaid coverage are not eligible to be a Member.
4. MEMBERSHIP RATES:
  1. Member will be responsible for Dues of Fifty-Five Dollars ($66.00) per month.
  2. Member will be responsible for a per visit utilization fee of Thirty-Five Dollars ($42.00) to be collected at the time of service.
  3. Member will be responsible for Dues of Fifty-Five Dollars ($66.00) per month, for each additional Family Member to their main Membership, up to a maximum of Two Hundred Twenty Dollars ($264.00) per family per month.
  4. Primary Member understands that they are responsible for payment of their Dues as well as those of all other Family Members covered under their Membership.
5. AUTOMATIC PAYMENTS:
  1. Member understands their Membership Dues are paid by automatic withdraw/charge.
  2. Member herein:
    1. Grants Family Medical Walk-In Clinics, Inc. permission to make such withdraws/charges.
    2. Agrees to provide Family Medical Walk-In Clinics, Inc. with accurate and valid account information to perform such withdraws/charges.
    3. Agrees to provide the identified entity (Bank, Savings Institution, etc.) from which these withdraws/charges are to be made with all notice and documentation that may be required.
  3. If the 15th falls during the weekend or a banking holiday it will be withdrawn on the last day prior to the 15th.
6. TREATMENT INCLUDED IN MEMBERSHIP:
  1. Only those healthcare services then provided by Family Medical Walk-In Clinics, Inc. in the normal course of business subject to the sole discretion of Family Medical Walk-In Clinics, Inc.
  2. Treatment that is currently included within the Membership:
    1. Urgent care, primary care office visits (Missouri locations only), routine physicals, laboratory tests performed on site at Family Medical Walk-In Clinics, Inc. clinics (i.e. blood sugar, pulse ox, urinalysis, pregnancy test, strep screens, hemacue, flu screens), x-rays, EKG’s, IV fluid administration, respiratory therapy, simple laceration repair, injections, injectable medicines, tetanus immunization, flu vaccines when available, splints, slings, and office procedures that are then provided in our clinics.
7. TREATMENT EXCLUDED FROM MEMBERSHIP:
  1. Prescriptions
  2. Services that Family Medical Walk-In Clinics, Inc. will not provide at the time Member seeks medical care.
  3. Member understands that the list below is provided for example only and does not include all of the services that are excluded from coverage under the terms of their Membership. Excluded services include:
    1. Life threatening events such as gun-shot wounds, heart attacks, and serious infections, hospitalizations and treatment with other doctors or providers at another facility that is not Family Medical Walk-In Clinics, Inc., special diagnostic studies such as outside labs, ultrasounds, doppler studies, mammograms, MRI’s, CAT scans, PET scans, and other special x-rays that are not provided at Family Medical Walk-In Clinics, Inc., physical and occupational therapy, chronic pain management, psychiatric emergency management, outpatient pharmacy, work injuries and other workers compensation services and any emergency care that the attending physician or mid-level Provider believes should, in the best interest of the Member, be provided by another Facility.
8. MEMBER USAGE:
  1. Certain situations may require further medical attention including but not limited to: medical prescriptions, referral to a specialist, referral to a hospital, or treatment that is not included in your Membership. The cost of any charges associated with these additional services are NOT covered by this Membership. Any such cost are the sole responsibility of the Member.
  2. Family Medical Walk-In Clinics, Inc. reserves the right, in its sole discretion, to cancel Membership for inappropriate use of the urgent care or appointment based services, including but not limited to request for services that are not then currently provided at Family Medical Walk-In Clinics, Inc.
  3. The attending physician or mid-level Provider will determine the appropriateness of Members’ visit.
9. TERMINATION OF MEMBERSHIP:
  1. Membership may be terminated by any of the following methods:
    1. Member provides the Family Medical Walk-In Clinics, Inc. corporate office with written notice of termination via certified letter or online through our Cancellation Request Page. Member benefits will end at the end of the month in which the notice of termination was received, if the cancellation request is RECEIVED by the 8th of the month; otherwise, membership will not be cancelled until the following month.
    2. Member fails to allow Family Medical Walk-In Clinics, Inc. the authority to withdraw/charge the monthly fee.
    3. Family Medical Walk-In Clinics, Inc. has the right to cancel Memberships at any time for any reason. If they choose to terminate the Member’s Membership, that termination will become effective immediately.
  2. Falsification of identification or failure to pay will result in immediate termination of Membership, assessment of utilization fee, full price charges for any services rendered, and the full pursuit of the legal rights held by Family Medical Walk-In Clinics, Inc.
10. REACTIVATING A CANCELLED MEMBERSHIP:
  1. A cancelled Member must pay $132 to reactivate within 12 months of cancellation in addition to first and last months of membership dues. ($264 total).
  2. Subject to prepayment under 10a., an individual may reactivate Membership 12 months after cancellation without penalty.
  3. Family Medical Walk-In Clinics, Inc. reserves the right to deny the renewal privileges of any Membership
11. CHANGES IN PERSONAL INFORMATION:
  1. Members must inform Family Medical Walk-In Clinics, Inc. in a timely manner of all changes to billing information.
  2. If Family Medical Walk-In Clinics, Inc. is not able to receive payment of monthly dues because of changes in billing information not being provided, a fee of $25.00 per month will be assessed on a monthly basis in addition to Dues until the Member provides Family Medical Walk-In Clinics, Inc. with their correct billing information, or until their Membership is terminated.
  3. This additional monthly charge is subject to change without notice.
12. WAIVER:
  1. The failure by Family Medical Walk-In Clinics, Inc. to exercise or enforce any of the terms or conditions of this Terms and Conditions of Membership is not to be deemed a waiver of Family Medical Walk-In Clinics, Inc. rights to enforce each and every term hereof. The failure by Family Medical Walk-In Clinics, Inc. to insist upon strict performance of any of the terms or conditions of the Terms and Conditions of Membership will not be deemed a waiver of any subsequent breach or default in the terms or provisions herein.
13. ASSIGNMENT:
  1. This Membership may not be assigned or transferred.
14. LIMITATION OF ACTIONS:
  1. Any legal action against Family Medical Walk-In Clinics, Inc. for a default of its obligations to the Member must be commenced within one (1) year from the date the default was, or should have been, discovered.
15. FORCE MAJEURE:
  1. Family Medical Walk-In Clinics, Inc. is not liable for any delay or failure of performance caused by strikes, insurrection, war, fire, electrical failure, brown-outs, disruption of transmission lines, government acts or regulations, acts of third parties, or any cause not within the control of Family Medical Walk-In Clinics, Inc.
16. GOVERNING LAW:
  1. The validity, construction, and interpretation of this Agreement and the rights and duties of the parties hereto will be governed by the laws of Missouri without regard to choice of law principles.
17. VENUE:
  1. The exclusive venue for any litigation arising out of, or related to, these Terms and Conditions of Membership will be Greene County, Missouri.
18. ENTIRE AGREEMENT:
  1. These Terms and Conditions of Membership constitute the entire agreement between the parties relating to the specific subject matter hereof. There are no terms, obligations, covenants, representatives, statements, or conditions other than those contained herein. No variation or modification of these Terms and Conditions of Membership or waiver of any of the terms or conditions hereof, except that Family Medical Walk-In Clinics, Inc. may add or cease medical services it provides and included under the terms hereof, at its sole discretion will be deemed valid unless in writing and signed by both parties.
19. UNENFORCEABLE TERMS:
  1. If any provision of these Terms and Conditions of Membership is held invalid, illegal, or unenforceable, these Terms and Conditions of Membership will be interpreted as if such provision, to the extent the same has been held invalid, illegal, or unenforceable, had never been contained herein.
20. SUCCESSORS:
  1. These Terms and Conditions of Membership shall be binding upon and inure to the benefit of the parties hereto and their respective heirs, successors, or executors.
21. NOTICES:
  1. Any notice required or allowed to be given shall be addressed to the other party at the address set forth immediately below or to such other address as either party may instruct the other party in writing in accordance with this Section 21.
I have read and understand the "Terms and Conditions" listed above for the Family Medical Walk-in Clinics, Inc. "Affordable Care Solutions" Membership and agree to abide by all the terms and conditions listed therein.
Enter your initials:*

Save and Continue Later

Please complete this form within the next 5:00, once completed please sign your name below acknowledging that all the information provided to us is correct, and press submit.

Hidden
Membership Pricing
- Individual
- Individual + 1 Member
- Individual + 2 Member
- Individual + 3 or More Members
Membership Fee
Price: $0.00
Membership Fee
Price: $0.00
Product Name
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
SCOPE OF SERVICE POLICY

Affordable Care Solutions is strictly a membership program with Family Medical Walk-In Clinics, Inc. and cannot be used for any services outside of our locations such as outpatient diagnostic tests or hospitalization. With this membership program, you can use your card at any of our locations for minor illness, injury, and primary care. If you are unfamiliar with our locations, please visit our website at www.fmwic.com . A membership includes a $66 monthly membership program fee with $42 fee for office visit.

This membership program covers urgent care and primary care office visits, routine physicals, laboratory tests performed on-site at any Family Medical Walk-In Clinics, Inc. location (such as blood sugar, pulse ox, urinalysis, pregnancy test, strep screens, hemocue, or flu screens), x-rays, EKG’s, IV fluid administration, respiratory therapy, simple laceration repair, injections, injectable medicines, tetanus immunization, flu vaccines when available, splints, slings, and office procedures that are provided in the clinics.

However, this program does not cover any outside labs, prescriptions, or workman’s comp. While you do have access to outside labs through our facility, if the provider determines a need to perform any of these, we will let you know the additional costs.

PRIVACY POLICY:

"We respect and are committed to protecting your privacy. We may collect personally identifiable information when you visit our site. We also automatically receive and record information on our server logs from your browser including your IP address, cookie information and the page(s) you visited. We will not sell your personally identifiable information to anyone."

SECURITY POLICY:

"Your payment and personal information is always safe. Our Secure Sockets Layer (SSL) software is the industry standard and among the best software available today for secure commerce transactions. It encrypts all of your personal information, including credit card number, name, and address, so that it cannot be read over the internet."

CANCELLATION POLICY:

Membership cancellations must be received by the 8th of the month in order to stop your automatic withdrawal for the 15th.
Two ways a membership can be cancelled by the member::
1. A certified letter must be sent to 4049 S. Campbell, Springfield, MO 65807
a. Must list the cancelling member's name, DOB and reasoning for cancelling

2. You can go online to cancel your membership @ www.fmwic.com
•Note: Letters and online requests received after the 8th of the month will have their auto withdrawals stopped on the 15th of the following month

Three ways a membership can be cancelled by Family Medical Walk-In Clinics, Inc.:
1. Member fails to allow Family Medical Walk-In Clinics, Inc. the authority to withdraw/charge the monthly fee
2. Family Medical Walk-In Clinic, Inc. has the right to cancel Memberships at any time for any reason. If they choose to terminate the member’s membership, the termination will become effective immediately
3. Falsification of identification or failure to pay will result in immediate termination of membership, assessment of utilization fee, full price charges for any services rendered, and the full pursuit of the legal rights held by Family Medical Walk-In Clinics, Inc.
I have read and agree to the above terms*
- Yes, I have read and agree to the above terms
Signature
CAPTCHA

Save and Continue Later

Transaction Information
Transaction Number :	10986
Transaction Amount :	$0.00
Tax Amount :	$0.00
Total Amount :	$0.00

First Name*	M.I.	Last Name*	Relationship*	DOB*	Gender*	SSN