Independent Practitioner. Practitioner and Client acknowledge and agree that Practitioner is an independent health professional and not an employee, contractor or representative of the Pastoral Medical Association*, and that Practitioner is solely responsible for Practitioner’s actions, suggestions, services and/or products. Practitioner and Client further acknowledge and agree that the Pastoral Medical Association does not have, incur or accept any responsibility or liability for Practitioner’s actions, suggestions, services and/or products, or in any manner guarantee or promise Client’s overall success or any particular results in following Practitioner’s advice or accepting Practitioner’s services pursuant to this Agreement. Therefore, Practitioner and Client hereby agree to indemnify and hold the Pastoral Medical Association harmless for any claim or action based on the parties entering into this Agreement for Wellness Services, or on the advice or services provided by Practitioner to the Client, or on the failure of the Client to achieve desired health outcomes. In this regard, the Parties hereto also agree that the Pastoral Medical Association is a third-party beneficiary of this Agreement and that this provision No. 6 relating non-responsibility and indemnification of the Pastoral Medical Association is binding on the Parties and may not be modified without the specific prior written consent of the Pastoral Medical Association.
Independent Practitioner. All treatments and procedures provided are between Xxxxxxx Xxxxxxx, NP and patient. Xxxxxxx Xxxxxxx, NP is not an employee at Embody Wellness and is providing care at this facility as an Independent practitioner. (Initials) By signing this Agreement, You indicate that You have read, understood and agree to its terms, You have received a copy of this Agreement, and that You are the patient, Guarantor, the patient’s legal representative or legally authorized to sign this Agreement and accept its terms. Patient Name (Print) Legal Guardian Signature Date Signature Date I Xxxxxxx Xxxxxxx, NP, hearby certify that I have explained to the patient or authorized person the nature of the proposed treatments, the medically significant alternatives, and in lay terms the purpose, likelihood of success, benefits, and reasonably foreseeable risks, complications, and consequences of treatment. The patient or person authorized has had the opportunity to ask questions and has stated that no further explanation was desired. Nurse Practitioner Signature (Xxxxxxx Xxxxxxx, NP) Date PATIENT/PROVIDER AGREEMENT FORM Xxxx Xxx Xxxxxxx NP. DESCRIPTION OF SERVICES: Xxxxxxx provides a comprehensive evaluation of your hormones and lifestyle. She will optimize any hormone deficiencies with bio-identical hormone replacement therapy, nutrition and supplementation. While Xxxxxxx is devoted to supporting her patients in optimal health and has a successful history of doing so, she is not solely responsible for your health results. Whole lifestyle approach and personal accountability are crucial pieces to having health, vitality and wellbeing. This is a cash pay practice, we do not bill Insurance. PROVIDER CONTACT GUIDELINES: In order to keep our prices accessible and balance Xxxxxxx’s schedule, you will be required to schedule an appointment for most questions and concerns. Please note that our office is not a concierge or boutique type practice. These types of concierge services charge thousands of dollars annually and include 24/7 availability and same day service. If you have administrative questions call the office at (000) 000-0000. If you have health related questions that are not an emergency (for emergencies you must call 911) please email Xxxxxxxxxxxxxxxx@xxxxxxxxxxxxxx.xxx and allow 72 hours for a response. This contract signs you up for our email newsletter. This is our primary source of communication regarding important policy and price changes. It also gives supportive health info...
Independent Practitioner. I work in an office with therapists who are independently practicing professionals who share certain expenses and administrative functions. While the members share office space, I want you to know that I am completely independent in providing you with clinical services and I alone am fully responsible for those services. My professional records are separately maintained and no member of the group can have access to them without your specific, written permission.
