Common use of Specialist Coordination Clause in Contracts

Specialist Coordination. The Clinic shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the Clinic physicians and medical staff. APPENDIX B PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Monthly fees, as set out in Appendix C, shall apply to the following Patient(s): / / Printed Name of Member 1 Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Cell Phone (required) Preferred email (required) / / Printed Name of Member 2 Date of Birth (MM/DD/YYYY) Age Home Phone Cell Phone (required) Preferred email (required) Child/Children to Whom this Agreement Applies: / / Printed Name Date of Birth (MM/DD/YYYY) / / Age Printed Name Date of Birth (MM/DD/YYYY) / / Age Printed Name Date of Birth (MM/DD/YYYY) / / Age Printed Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □Yearly (Credit/Debit Card/Bank Draft) □Monthly (Credit/Debit Card/Bank Draft) *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in this Medical Agreement Form. / / Signature of Member 1 Date / / Signature of Member 2 Date APPENDIX C FEE ITEMIZATION 0-18 years of age $20.00 per month* 19-55 years of age $60.00 per month 56+ years of age $80.00 per month Re Enrollment Fee $200.00 per person** *With the enrollment of at least one adult member, otherwise will be $60.00/month. **Non-refundable fee. Should your membership lapse or be terminated, the re enrollment fee must be paid for membership to become active. Re enrollment will be considered on a case by case basis. Name Fee Name Fee Name Fee Name Fee Name Fee Name Fee

Specialist Coordination. The Clinic and Physician shall coordinate as best as possible given the constraints in interoperability in the current healthcare system with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the Clinic physicians and medical staffCLINIC Physician. APPENDIX B PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Monthly fees, Fees as set out in Appendix C, C shall apply to the following Patient(s): / / Printed )*, who by signing this agreement certify that they have read, understand, and agree to the terms and conditions set forth in the KANSAS CITY DIRECT PRIMARY CARE Patient Agreement Form and have been offered a copy of the agreement. Head of Household - Print Name of Member 1 Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Cell Phone (required) Preferred email I consent to receiving communications from the clinic to the above email address and/or cell number [ ] YES or [ ] NO (requiredInitial) / / Printed Name of Member 2 Date of Birth (MM/DD/YYYY) Age Home Phone Cell Phone (required) Preferred email (required) Child/Children ____________________________________________________________________________________________ Spouse to Whom this Agreement Applies: / / Printed Name Date of Birth Applies (MM/DD/YYYYi.e. enrolling for care) / / Age Printed Name Date of Birth (MM/DD/YYYY) / / Age Printed Name Date of Birth (MM/DD/YYYY) / / Age Printed Spouse’s Name Date of Birth (MM/DD/YYYY) Age Spouse’s Cell Phone Spouse’s Preferred Payment MethodEmail I consent to receiving communications from the clinic to the above email address and/or cell number [ ] YES or [ ] NO (Initial) APPENDIX B, CONTINUED Child/Children to Whom this Agreement Applies* □Yearly (Credit/Debit Card/Bank Drafti.e. enrolling for care) □Monthly (Credit/Debit Card/Bank DraftName of Legal Guardian(s): Relationship: I, the above named legal guardian of the child(ren) *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have readage of 18 whose names appear on this document, understandconsent to receiving communications regarding such children, and agree from the Clinic by text to the terms set forth in this Medical Agreement Form. / / Signature cell number(s) and/or email address(es) provided above [ ] YES or [ ] NO (Initial) Child’s Name Date of Member 1 Date / / Signature of Member 2 Date APPENDIX C FEE ITEMIZATION 0-18 years of age $20.00 per month* 19-55 years of age $60.00 per month 56+ years of age $80.00 per month Re Enrollment Fee $200.00 per person** *With the enrollment of at least one adult member, otherwise will be $60.00Birth (MM/month. **Non-refundable fee. Should your membership lapse or be terminated, the re enrollment fee must be paid for membership to become active. Re enrollment will be considered on a case by case basis. Name Fee Name Fee Name Fee Name Fee Name Fee Name FeeDD/YYYY) Age Child’s Cell Phone Child’s Preferred Email

Specialist Coordination. The Clinic and Physician shall coordinate as best as possible given the constraints in interoperability in the current healthcare system with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the Clinic physicians and medical staffCLINIC Physician. APPENDIX B PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Monthly fees, Fees as set out in Appendix C, C shall apply to the following Patient(s): / / Printed )*, who by signing this agreement certify that they have read, understand, and agree to the terms and conditions set forth in the KANSAS CITY DIRECT PRIMARY CARE Patient Agreement Form and have been offered a copy of the agreement. Unless requested and approved in writing, new members will be assigned to the KCDPC physician with the most availability. Head of Household - Print Name of Member 1 Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Cell Phone (required) Preferred email I consent to receiving communications from the clinic to the above email address and/or cell number [ ] YES or [ ] NO (requiredInitial) / / Printed Name of Member 2 Date of Birth (MM/DD/YYYY) Age Home Phone Cell Phone (required) Preferred email (required) Child/Children ____________________________________________________________________________________________ Spouse to Whom this Agreement Applies: / / Printed Name Date of Birth Applies (MM/DD/YYYYi.e. enrolling for care) / / Age Printed Name Date of Birth (MM/DD/YYYY) / / Age Printed Name Date of Birth (MM/DD/YYYY) / / Age Printed Spouse’s Name Date of Birth (MM/DD/YYYY) Age Spouse’s Cell Phone Spouse’s Preferred Payment Method* □Yearly Email I consent to receiving communications from the clinic to the above email address and/or cell number [ ] YES or [ ] NO (Credit/Debit Card/Bank Draft) □Monthly (Credit/Debit Card/Bank DraftInitial) *All patients must have a credit or debit card on file file to cover the cost of membership and & any incidentals not covered under the Agreement. I certify that I have readAPPENDIX B, understandCONTINUED Child/Children to Whom this Agreement Applies* (i.e. enrolling for care) Name of Legal Guardian(s): Relationship: I, and agree the above named legal guardian of the child(ren) under the age of 18 whose names appear on this document, consent to receiving communications regarding such children, from the Clinic by text to the terms set forth in this Medical Agreement Form. / / Signature cell number(s) and/or email address(es) provided above [ ] YES or [ ] NO (Initial) Child’s Name Date of Member 1 Date / / Signature of Member 2 Date APPENDIX C FEE ITEMIZATION 0-18 years of age $20.00 per month* 19-55 years of age $60.00 per month 56+ years of age $80.00 per month Re Enrollment Fee $200.00 per person** *With the enrollment of at least one adult member, otherwise will be $60.00Birth (MM/month. **Non-refundable fee. Should your membership lapse or be terminated, the re enrollment fee must be paid for membership to become active. Re enrollment will be considered on a case by case basis. Name Fee Name Fee Name Fee Name Fee Name Fee Name FeeDD/YYYY) Age Child’s Cell Phone Child’s Preferred Email

Specialist Coordination. The Clinic and Physician shall coordinate as best as possible given the constraints in interoperability in the current healthcare system with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the Clinic physicians and medical staffCLINIC Physician. APPENDIX B PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Monthly fees, Fees as set out in Appendix C, C shall apply to the following Patient(s): / / Printed )*, who by signing this agreement certify that they have read, understand, and agree to the terms and conditions set forth in the KANSAS CITY DIRECT PRIMARY CARE Patient Agreement Form and have been offered a copy of the agreement. Unless requested and approved in writing, new members will be assigned to the KCDPC physician with the most availability. Head of Household - Print Name of Member 1 Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Cell Phone (required) Preferred email I consent to receiving communications from the clinic to the above email address and/or cell number [ ] YES or [ ] NO (requiredInitial) / / Printed Name of Member 2 Date of Birth (MM/DD/YYYY) Age Home Phone Cell Phone (required) Preferred email (required) Child/Children ____________________________________________________________________________________________ Spouse to Whom this Agreement Applies: / / Printed Name Date of Birth Applies (MM/DD/YYYYi.e. enrolling for care) / / Age Printed Name Date of Birth (MM/DD/YYYY) / / Age Printed Name Date of Birth (MM/DD/YYYY) / / Age Printed Spouse’s Name Date of Birth (MM/DD/YYYY) Age Spouse’s Cell Phone Spouse’s Preferred Payment Method* □Yearly Email I consent to receiving communications from the clinic to the above email address and/or cell number [ ] YES or [ ] NO (Credit/Debit Card/Bank Draft) □Monthly (Credit/Debit Card/Bank DraftInitial) *All patients must have a credit or debit card on file to cover the cost of membership and & any incidentals not covered under the Agreement. I certify that I have readAPPENDIX B, understandCONTINUED Child/Children to Whom this Agreement Applies* (i.e. enrolling for care) Name of Legal Guardian(s): Relationship: I, and agree the above named legal guardian of the child(ren) under the age of 18 whose names appear on this document, consent to receiving communications regarding such children, from the Clinic by text to the terms set forth in this Medical Agreement Form. / / Signature cell number(s) and/or email address(es) provided above [ ] YES or [ ] NO (Initial) Child’s Name Date of Member 1 Date / / Signature of Member 2 Date APPENDIX C FEE ITEMIZATION 0-18 years of age $20.00 per month* 19-55 years of age $60.00 per month 56+ years of age $80.00 per month Re Enrollment Fee $200.00 per person** *With the enrollment of at least one adult member, otherwise will be $60.00Birth (MM/month. **Non-refundable fee. Should your membership lapse or be terminated, the re enrollment fee must be paid for membership to become active. Re enrollment will be considered on a case by case basis. Name Fee Name Fee Name Fee Name Fee Name Fee Name FeeDD/YYYY) Age Child’s Cell Phone Child’s Preferred Email

Specialist Coordination. The Clinic shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the Clinic physicians and medical staff. APPENDIX B PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Monthly fees, as set out in Appendix C, shall apply to the following Patient(s): / / Printed Name of Member 1 Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Cell Phone (required) Preferred email (required) / / Printed Name of Member 2 Date of Birth (MM/DD/YYYY) Age Home Phone Cell Phone (required) Preferred email (required) Child/Children to Whom this Agreement Applies: / / Printed Name Date of Birth (MM/DD/YYYY) / / Age Printed Name Date of Birth (MM/DD/YYYY) / / Age Printed Name Date of Birth (MM/DD/YYYY) / / Age Printed Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □Yearly (Credit/Debit Card/Bank Draft) □Monthly (Credit/Debit Card/Bank Draft) *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in this Medical Agreement Form. / / Signature of Member 1 Date / / Signature of Member 2 Date APPENDIX C FEE ITEMIZATION 0-18 years of age $20.00 15.00 per month* 19-55 years of age $60.00 55.00 per month 56+ years of age $80.00 75.00 per month Re Enrollment Fee $200.00 150.00 per person** *With the enrollment of at least one adult member, otherwise will be $60.0055.00/month. **Non-refundable fee. Should your membership lapse or be terminated, the re enrollment fee must be paid for membership to become active. Re enrollment will be considered on a case by case basis. Name Fee Name Fee Name Fee Name Fee Name Fee Name Fee

Specialist Coordination. The Clinic shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the Clinic physicians and medical staff. APPENDIX B PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Monthly fees, as set out in Appendix C, shall apply to the following Patient(s): / / Printed Name of Member 1 Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone (required) Preferred email (required) / / Printed Spouse Name of Member 2 Date of Birth (MM/DD/YYYY) Age Home Phone Work Phone Cell Phone (required) Preferred email (required) Child/Children to Whom this Agreement Applies: / / Printed Name Date of Birth (MM/DD/YYYY) Age / / Age Printed Name Date of Birth (MM/DD/YYYY) Age / / Age Printed Name Date of Birth (MM/DD/YYYY) Age / / Age Printed Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □Yearly (Credit/Debit Card/Bank Draft) □Monthly (Credit/Debit Card/Bank Draft) *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in this Medical Agreement Form. / / Signature of Member 1 Date / / Signature of Member 2 Date APPENDIX C FEE ITEMIZATION 0-18 years of age $20.00 15.00 per month* 19-55 years of age $60.00 55.00 per month 56+ years of age $80.00 75.00 per month Employee based $55.00 per month Re Enrollment Fee $200.00 150.00 per person** *With the enrollment of at least one adult member, otherwise will be $60.0055.00/month. **Non-refundable fee. Should your membership lapse or be terminated, the re enrollment fee must be paid for membership to become active. Re enrollment will be considered on a case by case basis. Name Fee Name Fee Name Fee Name Fee Name Fee Name Fee