MEMBERSHIP CONTRACT TIER 1 DOCTOR/CLINIC
THE FORGOTTEN FORMULA PMA
A Private Membership Association
I, , for membership fee paid in hand, do hereby apply for membership in The Forgotten Formula PMA, a private membership organization. With the signing of this membership agreement, I/we accept the offer made to become a member of The Forgotten Formula PMA and have read and agree with the following Declaration of Purpose from Article I of The Forgotten Formula PMA’s Articles of Association.
IT IS HEREBY Declared that we are exercising our right of “freedom of association” as guaranteed by the First and Fourteenth Amendments of the U.S. Constitution and equivalent provisions of the various state constitutions. This means that our Association activities are restricted to the private domain only.
a.) Educating clinics and doctors as well as private members in regard to holistic, medical practices proven to eradicate certain illnesses.
b.) Sharing knowledge among members to help them heal themselves.
c.) Focusing on the root cause of illness in healing the body, mind and spirit.
d.) Speaking and sharing freely about the data, research, and the member’s own individual ailments. e.) Offering direct counseling to doctors and clinicians seeking alternative healing processes.
The products offered are whole plant, CGMP ISO22000 manufactured, non-gmo certified organic products that consist of advanced phyto-therapeutics, ecs activation sirtuin activation, whole plant vitamins, minerals, and a wide variety of nutritional supplements that are designed to complement our protocols and programs which focus on root cause of the problem.
f.) The Association will offer its members concierge stem cell services as assessed on an individual basis. As alternates and for the benefit of its members.
MEMORANDUM OF UNDERSTANDING
I understand that the fellow members of the Association that provide services and care, do so in the capacity of a fellow member and not in the capacity as a licensed health care provider. I further understand that within the association no doctor-patient relationship exists but only a contract member-member Association relationship. In addition, I have freely chosen to change my legal status as a public patient or client to a private member of the Association. I further understand that it is entirely my own responsibility to consider the advice and recommendations offered to me by my fellow members and to educate myself as to the efficacy, risks, and desirability of the same and the acceptance of the offered or recommended diagnosis, therapy, treatment and care is my own carefully considered decision. Any request by me to a fellow member to assist me or provide me with the aforementioned diagnosis, therapy, treatment and care is my own free decision in an exercise of my rights and made by me for my benefit, and I agree to hold the Trustee(s), staff and other worker members and the Association harmless from any unintentional liability for the results of such care, except for harm that results from instances of a clear and present danger of substantive evil as determined by the Association, as stated and defined by the United States Supreme Court.
The Trustee and members have chosen Michael Blake Fiveash as the person best qualified to perform services to members of the Association and entrust him to select other members to assist him in carrying out that service.
In addition, I understand that since the Association is protected by the First and Fourteenth Amendments to the U.S. Constitution, it is outside the jurisdiction and authority of Federal and State Agencies and Authorities concerning any and all complaints or grievances against the Association, any Trustee(s), members or other staff persons. All rights of complaints or grievances will be settled by an Association Committee and will be waived by the member for the benefit of the Association and its members. Because the privacy and security of membership records maintained within the Association which have been held to be inviolate by the U.S. Supreme Court, the undersigned member waives HIPAA privacy rights and complaint process. Any medical or healthcare records kept by the association will be strictly protected and only released upon written request of the member. I agree that violation of any waivers in this membership contract will result in a no contest legal proceeding against me. In addition, the Association does not participate in any medical insurance plans or collections on behalf of the member but will provide a suitable invoice for the member to pursue reimbursement by his/her insurance company, if applicable.
I agree to join the Association, a private membership association under common law, whose members seek to help each other achieve better health and live longer with good quality of life.
I understand that the doctors, nurses, and other providers who are fellow members of the Association are offering me advice, services, and benefits that do not necessarily conform to conventional medical care. I do not expect these benefits to include on-call coverage, hospital care, or the usual and customary care provided by most physicians. I will receive such primary and specialist care elsewhere. I fully understand that the benefits I receive from the Association might or might not be covered by my health insurance and not at all by Medicare.
As a member, I accept the goals of helping my body function better and choosing techniques that are both very safe and have a reasonably good chance to succeed, realizing that no diagnostic technique or treatment is foolproof. If I choose to forgo drugs, surgery, or radiation that has been recommended to me by others, I fully accept the risk that I might suffer serious consequences from that choice. Other aspects of informed consent will take place in my discussions with the providers and my fellow members of the Association.
My activities within the Association are a private matter that I refuse to share with the State Medical Board, the FDA, FTC, Medicare, Medicaid or my own insurance company without my expressed specific permission. All records and documents remain as property of the Association, even if I receive a copy of them. I fully agree not to file a malpractice lawsuit against a fellow member of the Association unless that member has exposed me to a clear and present danger of substantive evil. I acknowledge that the members of the Association do not carry malpractice insurance.
I enter into this agreement of my own free will or on behalf of my dependent without any pressure or promise of cure. I affirm that I do not represent any State or Federal agency whose purpose is to regulate and approve products. I have read and understood this document, and my questions have been answered fully to my satisfaction. I understand that I can withdraw from this agreement and terminate my membership in this association at any time. These pages and Article I of the Articles of Association of the Association consist of the entire agreement for my membership in the Association and they supersede any previous agreement.
I understand that the membership fee entitles me to receive those benefits declared by the Trustee(s) to be “general benefits” free of further charge. I agree to pay as levied those benefits that I receive that are declared by the Trustees to be “special assessments”, per Fee Schedule.
I enclose the sum that is applicable to my tier of membership. Tier is defined as either non doctor , doctor/clinic, wholesale or seminar as consideration for my yearly membership contract as defined in the articles of association, said term beginning with the date of the signing of this contract, and by these presents do hereby certify, attest and warrant that I have carefully read the above and foregoing The Forgotten Formula PMA’s Contractual Application for Membership and I fully understand and agree with same. I enclose the initial fee of $1200 dollars or $70.00/month which will renew annually on this date unless paid in full thereby granting lifetime membership. IN WITNESS WHEREOF I set my hand this day of , 20 .
Member’s Name (Name of legal guardian if Applicant under 18 years, if applicable)
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Member’s Signature (Signature of legal guardian if Applicant under 18 years, if applicable)
Member’s Contact Information:
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home/work/cell numbers email address
For office use only: The Forgotten Formula PMA
A Private Membership Association Approved and accepted this ____ day of _________ 20____
by:_____________________________ ____________________
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Signed by Michael Fiveash Signed On: April 15, 2024
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Document Name: MEMBERSHIP CONTRACT TIER 1 DOCTOR/CLINIC
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