Practice Policies, Financial Responsibility & Billing Authorization Sample Contracts
PRACTICE POLICIES, FINANCIAL RESPONSIBILITY & BILLING AUTHORIZATIONPractice Policies, Financial Responsibility & Billing Authorization • December 10th, 2017
Relationship and Scope of Practice. By signing this agreement I am seeking medical service from, and entering into an agreement as detailed herein with Chingchai Wanidworanun, MD, PLLC which is a business entity whose addresses are shown above, and whose membership includes and is not limited to Chingchai Wanidworanun, MD hereinafter referred as The Doctor, who is also known as Dr. Chingchai Wanid. I accept that Chingchai Wanidworanun, MD, PLLC hereinafter referred to as The Practice provides medical services within the scope of general internal medicine and that there are other services including but not limited to travel medicine and vaccination that are not provided by The Practice. Each of my office visit with The Doctor defines my relationship with The Doctor and The Practice and the other parties involved, and its nature and its term. For example, The Doctor is my primary care doctor if I maintain an annual routine visit for health maintenance with The Doctor. If I see The Doctor