Patient Understandings a. This Agreement is for ongoing primary care and is NOT a medical insurance agreement.
Patient Understandings. By executing this Patient Agreement, Patient understands and agrees to all of the listed Patient Understandings below. ✓ This Agreement is for ongoing primary care and is NOT a medical insurance agreement. ✓ I do NOT have an emergent medical problem at this time. ✓ In the event of a medical emergency, I agree to call 911 first. ✓ I understand the Practice will make every effort to be available but may not always be able to me on a same-day basis. I may, only when necessary, be referred to an urgent care for same-day service. ✓ I do NOT expect the practice to file or fight any third party insurance claims on my behalf. ✓ In the event I have a complaint about the Practice, I will first notify the Practice directly. ✓ This Agreement (without a “wrap around” compliant insurance policy) does not meet the individual insurance requirement of the Affordable Care Act.
Patient Understandings. This Agreement is for ongoing primary care and is NOT a medical insurance agreement. I do NOT have an emergent medical problem at this time. In the event of a medical emergency, I agree to call 911 first. I do NOT expect the practice to file or fight any third-party insurance claims on my behalf. I do NOT expect the practice to prescribe chronic controlled substances on my behalf. (These include commonly abused opioid medications, benzodiazepines, and stimulants.) In the event I have a complaint about the Practice, I will first notify the Practice directly. This Agreement (without a “wrap around” compliant insurance policy) does not meet the individual insurance requirement of the Affordable Care Act. I am enrolling (myself and my family if applicable) in the practice voluntarily. I may receive a copy of this document upon request. This Agreement is non-transferable. Patient Name Patient (or Guardian) Signature Nurse Practitioner Name Nurse Practitioner Signature APPENDIX 1 Dunes Family Clinic, LLC Periodic & Enrollment Fees This Agreement is for ongoing primary care. This is Agreement is NOT HEALTH INSURANCE and is NOT A HEALTH MAINTENANCE ORGANIZATION. The Patient may need to use the care of specialists, emergency rooms, and urgent care centers that are outside the scope of this Agreement. Each Nurse Practitioner within the Practice will make an appropriate determination about the scope of primary care services offered by the Nurse Practitioner. Examples of common conditions we treat, procedures we perform, and medications we prescribe are listed on our website and are subject to change. Fee Schedule Enrollment Fee: This is charged when the Patient enrolls with the Practice and is nonrefundable. This fee is subject to change. If a patient discontinues membership and wishes to re-enroll in the practice we reserve the right to decline re-enrollment or to require that the re-enrollment fee reflect an amount equivalent to the time of absent payments when dis-enrolled from the Practice. Your Enrollment fee is $0. Re-enrollment Fee: Requests to restart memberships are subject to approval and availability. If accepted, a minimum re-enrollment fee of $500 per person will apply before service can be restarted. Annual Periodic Fee: (billed at the beginning of the service period) – This fee is for ongoing primary care services. Unlimited scheduled in person visits per year are available to you at no additional cost. Your number of virtual visits (e-mail, electronic...
Patient Understandings. Patient hereby makes the following representations and warranties to the Company, all of which are material and are being relied upon by the Company:
Patient Understandings. This Agreement is for ongoing primary care and is NOT a medical insurance agreement. -I do NOT have an emergent medical problem at this time. -In the event of a medical emergency, I agree to call 911 first. -I do NOT expect the practice to file or fight any third party insurance claims on my behalf. -I do NOT expect the practice to prescribe chronic controlled substances on my behalf. (These include commonly abused opioid medications, benzodiazepines, and stimulants.) -In the event I have a complaint about the Practice I will first notify the Practice directly. -This Agreement (without a “wrap around” compliant insurance policy) does not meet the individual insurance requirement of the Affordable Care Act.
Patient Understandings. (initial each) This Agreement is for ongoing primary care only and does not cover specialty care or services. This Agreement is not a medical insurance agreement. I do NOT (and none of my family members if applicable) have an emergent medical problem at this time. I am enrolling (myself and my family members if applicable) in Inspire Family Medicine voluntarily. I understand that neither the Provider nor Inspire Family Medicine, is a Medicare provider. Therefore, the Provider will not submit claims to Medicare for covered services for those who have Medicare coverage. I understand that HMOs, TriCare and MassHealth may prevent me from getting referrals, labs and tests from an out-of-network provider. I do not expect Inspire Family Medicine to file, pursue, or dispute any third-party insurance claims on my behalf. I understand that I am enrolling in a membership-based practice for which I will pay in advance monthly. In the event of a medical emergency, I agree to call 911 first. I understand the Provider will make every effort to be available but may not always be able to see me on a same-day basis. I may be referred to an urgent care for same-day service. I understand that Inspire Family Medicine will be closed for vacation during the last week in December, every year, during which time, the Provider will NOT be available by phone, text, email or in-person and any urgent or emergent matters will need to be taken care of by a local Urgent Care center or Emergency Room. I understand that the Provider may, from time to time, take additional time off or attend medical conferences, during which periods she will not be available to see Patients in person. She may, at her discretion, provide consultation via text, video chat or phone, provide alternate coverage by a local colleague during this time, or advise Patients to seek care at a local Urgent Care center. Inspire Family Medicine will to make every reasonable attempt to notify the Patient, via email, with at least 1 week of advance notice of any such time off by Provider. This Agreement does not meet the individual insurance requirement of the Affordable Care Act. This Agreement is non-transferable. I understand failure to pay the membership fee on or before the monthly due date will result in termination from Inspire Family Medicine. The Parties may sign duplicate counterparts of this Agreement as of the date first written below. Xxxxxxxx XxXxxxx, MD, founder and CEO of Inspire Family Medicine Patient’s Nam...
Patient Understandings. By executing this Patient Agreement, Patient understands and agrees to all of the listed Patient Understandings below. ✓ This Agreement is for a single medical visit and is NOT a medical insurance agreement. ✓ I do NOT have an emergent medical problem at this time. (Call 911 for emergencies) ✓ I do NOT expect the practice to file or fight any third party insurance claims on my behalf. ✓ In the event I have a complaint about the Practice, I will first notify the Practice directly. ✓ This Agreement does not meet the individual insurance requirement of the Affordable Care Act.
Patient Understandings. This Agreement is for ongoing primary care or functional medicine and is NOT a medical insurance agreement. I do NOT have an emergency medical problem at this time. In the event of a medical emergency, I agree to call 911 first. I do NOT expect the practice to file or fight any third party insurance claims on my behalf. I understand that I am responsible for any laboratory charges and that Dr. B may recommend labs that are not covered by insurance. I do NOT expect the practice to prescribe chronic controlled substances on my behalf. (These include commonly abused opioid medications, benzodiazepines, and stimulants.) In the event I have a complaint about the Practice I will first notify the Practice/Physician directly. I am enrolling myself (and my family if applicable) in the practice voluntarily. I may receive a copy of this document upon request, and it is available on the website. This Agreement is non-transferable. I recognize that the Functional Medicine approach requires active participation, cooperation and positive, sustainable lifestyle changes to achieve the best outcomes. I assume the risks inherent in making lifestyle change, including the risks of trying new foods, supplements and fitness programs. This agreement is not a guarantee of health results.
Patient Understandings. A. This Agreement is for ongoing primary care and is NOT a medical insurance agreement.
