Acceptance of Patients. We reserve the right to accept or decline patients based upon our capability to appropriately handle the patient’s primary care needs. We may decline new patients pursuant to the guidelines proffered in Section 6 (Term), because the Physician’s panel of patients is full, or because the patient requires medical care not within the Physician’s scope of services. Appendix 2 OC Sports and Wellness Itemized Fees Ongoing Primary Care is included with the Periodic Fee described in Appendix 1. There are no itemized fees for office visits unless the patient has more than fifteen (15) scheduled in-office visits in a calendar year. In-Office Procedures we are generally comfortable performing the procedures listed on the Practice website. These are typically available at no additional cost unless otherwise designated, and these are also subject to change. Laboratory Studies will be drawn in the office at no additional charge and the Patient will be charged according to the direct price rate we have negotiated with the lab. An example of common laboratory studies and their prices (subject to change) are listed on the practice website. Medications will be ordered in the most cost-effective manner possible for the Patient. When we dispense medications in the office these medications will be made available to the patient at wholesale cost. Examples of commonly dispensed medications and their prices (subject to change) are listed on the practice website. Pathology studies (most commonly skin biopsies) will be ordered in the most economical manner possible. Anticipated prices for these studies (subject to change) are listed on the Practice website. Radiology studies will be ordered in the most cost-effective manner possible for the Patient. Commonly ordered radiologic studies and prices (subject to change) are listed on the website. Surgery and specialist consults will be ordered in the most cost-effective manner possible for the Patient. Gynecological (Well Woman) exams are done at no additional cost. The anticipated cost of the pap smear (subject to change) will be listed on the website. Vaccinations are NOT offered in our office at this time due to the cost prohibitive nature of stocking a limited supply. We will make an effort to help you obtain needed vaccinations else xxxx in the most cost-effective manner possible. Hospital Services are NOT covered by our membership plan, and due to mandatory “on call” duties required at local institutions we have elected NOT to obtain formal hospital admission privileges at this time. Obstetric Services are NOT covered by our membership plan.
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Acceptance of Patients. We reserve the right to accept or decline patients based upon our capability to appropriately handle the patient’s primary care needs. We may decline new patients pursuant to the guidelines proffered in Section 6 (Term), because the PhysicianProvider’s panel of patients is full, or because the patient requires medical care not within the PhysicianProvider’s scope of services. Appendix 2 OC Sports and Wellness Patient Name Patient (Guardian) Signature Date (MMDDYYYY) Direct Primary Care (DPC) Itemized Fees Ongoing Primary Care Care: is included with the Periodic Fee described in Appendix 1. There Please see a list of some of the acute and chronic conditions we routinely treat on the Practice website. Conditions we treat are no itemized fees for office visits unless the patient has more than fifteen (15) scheduled in-office visits in a calendar yearsubject to change. In-Office Procedures and Medications: Procedures we are generally comfortable performing the procedures are listed on the Practice website. These are typically available at no additional cost included with the Periodic Fee described in Appendix 1 unless otherwise designated, and designated on the website. Procedure fees are is subject to change. Medications may be administered in our office via an injectable or oral route. Patient will be charged our “BEST” price for these medications. Medication fees are also subject to change. Laboratory Studies Studies: We have the capability to draw blood for nearly any test you may need. Most lab specimens will be drawn processed by an outside facility. A listing of some common laboratory tests and their fees are cited on the Practice website. This list is not comprehensive. Laboratory fees are subject to change. Pathology: Pathology studies (most commonly skin biopsies and Paps) will be ordered in the office most economical manner possible and will be sent to an outside facility for analysis. Pathology fees are subject to change. Reflex Testing: Pricing for certain lab and pathology tests dependent on “reflex testing” (when a certain initial result requires additional testing on the same specimen) will not be known at no additional charge and the time of specimen submission, therefore, lab/pathology pricing, if cited on the Practice website, indicates the cost for the initial test. The Patient will be charged according for reflex testing once it is determined that a reflex test was required and performed on a specimen. Radiology: Radiology studies will be ordered in the most cost-effective manner. We do not provide radiology Services on site at this time, therefore, the pricing for such Services is determined by the outside facility performing such Services. Patients will be referred to the direct price rate we have an outside facility for all radiology procedures. Practice website will be updated with negotiated with the labprices as they become available. An example of common laboratory studies Surgery and their prices (subject Specialist Consults: Referrals to change) are listed on the practice website. Medications Surgeons and Specialists will be ordered in the most cost-effective manner possible for the Patient. When we dispense medications in Pricing for all outside specialty referrals is determined by the office these medications will be made available to the patient at wholesale costorganization you are being referred to. Examples of commonly dispensed medications and their prices (subject to change) are listed on the practice website. Pathology studies (most commonly skin biopsies) will be ordered in the most economical manner possible. Anticipated prices for these studies (subject to change) are listed on the Practice website. Radiology studies will be ordered in the most cost-effective manner possible for the Patient. Commonly ordered radiologic studies and prices (subject to change) are listed on the website. Surgery and specialist consults will be ordered in the most cost-effective manner possible for the Patient. Gynecological (Well Woman) exams are done at no additional cost. The anticipated cost of the pap smear (subject to change) will be listed on the website. Vaccinations: Vaccinations are NOT offered in our office at this time due to the cost prohibitive nature of stocking a limited supply. We will make an effort to help you obtain needed vaccinations else xxxx elsewhere in the most cost-effective manner possible. Hospital Services: Hospital Services are NOT covered provided by our membership planthe Practice, and due to mandatory “on call” duties required at local institutions hospital rules and regulations, we have elected NOT to obtain formal hospital admission privileges for direct care at this time. Obstetric Virtual Visits (Phone Visit and Televideo Visit): Practice may offer televideo and phone virtual visits to Patients. These visits typically are offered to Patients who have a minor condition that can be diagnosed with reasonable certainty without a face-to-face visit and to Patients who have had a recent visit which generated multiple lab abnormalities requiring further Provider consultation. This form of visit is offered by Provider discretion as a convenience to Patients where an office visit would normally be required. Virtual visit fees are included in the Monthly Periodic Fee. Other Services: Practice may add additional Services in the future. These will be posted on our website. Patient Name Patient (Guardian) Signature Date (MMDDYYYY) I, , have received a copy of Priority Medical Partners Direct, SC “Notice of Privacy Practices”. Patient’s Name Signature of Patient Date I authorize Priority Medical Partners Direct, SC to send email or text which may include unencrypted protected health information. (Providing us with authorization to email and text you will allow Priority Medical Partners Direct, SC to exchange information with you more efficiently and will benefit you as a patient. At the same time, we recognize that email and text messaging are NOT covered by not a completely secure means of communication. You are not required to authorize the use of email and text messages and a decision to not authorize electronic communication will not affect your health care in any way. We have taken considerable effort to protect the personal health information of our membership planpatients and recommend that all patients provide us with this authorization so that we can more efficiently communicate with them.) Name of Patient Signature of Patient Date
Appears in 1 contract
Samples: Membership Patient Agreement
Acceptance of Patients. We reserve the right to accept or decline patients based upon our capability to appropriately handle the patient’s primary care needs. We may decline new patients pursuant to the guidelines proffered in Section 6 (Term), because the Physician’s panel of patients is fullfull (capped at 300 patients or fewer), or because the patient requires medical care not within the Physician’s scope of services. This area was intentionally left blank Agreement continues on the next page* Appendix 2 OC Sports and Wellness Concierge Health Network Itemized Fees Ongoing Primary Care is included with the Periodic Fee described in Appendix 1. Please see a list of some of the chronic conditions we routinely treat on the Practice website or available at request (subject to change). There are no itemized fees for office visits unless the patient has more than fifteen (15) twenty scheduled in-office visits or twenty scheduled virtual appointments in a calendar year. In-Office Procedures we are generally comfortable performing the procedures are listed on the Practice websitewebsite or are available at request. These are typically available at no additional the wholesale cost of supplies necessary for the procedures being provided unless otherwise designated, noted and these are also subject to change. Laboratory Studies will be drawn in the office at no additional charge wholesale cost and the Patient will be charged according to the direct price rate we have negotiated with the labaccordingly. An example of common laboratory studies and their prices (subject to change) are listed on the practice websitewebsite or are available at request. Medications will be ordered in the most cost-cost effective manner possible for the Patient. When we dispense medications in the office these medications will be made available to the patient at wholesale cost. Examples of commonly dispensed medications and their prices (subject to change) are listed on the practice websitewebsite or are available at request. Pathology studies (most commonly skin biopsies) will be ordered in the most economical manner possible. Anticipated prices for these studies (subject to change) are listed on the Practice websitewebsite or are available at request. Radiology studies will be ordered in the most cost-cost effective manner possible for the Patient. Commonly ordered radiologic studies and prices (subject to change) are listed on the websitewebsite or are available at request. Surgery and specialist consults will be ordered in the most cost-cost effective manner possible for the Patient. Gynecological (Well Woman) exams are done at no additional cost. The anticipated cost of the pap smear (subject to change) will be listed on the website. Vaccinations are NOT offered in our office at this time due to the cost prohibitive nature of stocking a limited supply. We will make an effort to help you obtain needed vaccinations else xxxx in the most cost-cost effective manner possible. Hospital Services are NOT covered by our membership plan, and due to mandatory “on call” duties required at local institutions we have elected NOT to obtain formal hospital admission privileges at this time. Obstetric and Gynecologic Services are NOT covered by our membership plan. In the future we may begin to offer some of these outpatient services in our office, but due to our small size we are unable to offer these services at this time. I certify that I have read, understand, and agree to the terms set forth in Concierge Health Network’s Direct Primary Care Agreement. I further certify that I have received a copy of this Agreement. All payments are due and processed as outlined above. I certify that by providing my credit card or bank information through the online sign up, I authorize Practice and Physician to process payment as noted in the above Agreement.
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Acceptance of Patients. We reserve the right to accept or decline patients based upon our capability to appropriately handle the patient’s primary care needs. We may decline new patients pursuant to the guidelines proffered in Section 6 (Term), because the PhysicianProvider’s panel of patients is full, or because the patient requires medical care not within the PhysicianProvider’s scope of services. Appendix Patient Name Patient (Guardian) Signature Date (MM/DD/YYYY) APPENDIX 2 OC Sports and Wellness Direct Primary Care (DPC) Itemized Fees Ongoing Primary Care Care: is included with the Periodic Fee described in Appendix 1. There Please see a list of some of the acute and chronic conditions we routinely treat on the Practice website. Conditions we treat are no itemized fees for office visits unless the patient has more than fifteen (15) scheduled in-office visits in a calendar yearsubject to change. In-Office Procedures we and Medications: A list of common procedures and associated fees, if any based upon membership status, is available upon request. Procedure fees are generally comfortable performing the procedures listed on the Practice websitesubject to change. These Medications may be administered in our office via an injectable or oral route. Patient will incur an additional charge for these medications. Medication fees are typically available at no additional cost unless otherwise designated, and these are also subject to change. Laboratory Studies Studies: We have the capability to draw blood for nearly any test you may need. Most lab specimens will be drawn processed by an outside facility. A listing of some common laboratory tests and their fees are available upon request. This list is not comprehensive. Laboratory fees are subject to change. Pathology: Pathology studies (most commonly skin biopsies and Paps) will be ordered in the office most economical manner possible and will be sent to an outside facility for analysis. Pathology fees are subject to change. Reflex Testing: Pricing for certain lab and pathology tests dependent on “reflex testing” (when a certain initial result requires additional testing on the same specimen) will not be known at no additional charge and the time of specimen submission, therefore, lab/pathology pricing will not be known. The Patient will be charged according for reflex testing once it is determined that a reflex test was required and performed on a specimen. Radiology: Radiology studies will be ordered in the most cost-effective manner. We may provide certain Xray and ultrasound radiology Services on site. Prices will be disclosed to you at time of service. Pricing for all outside radiology referrals is determined by the direct price rate we have negotiated with the laborganization you are being referred to. An example of common laboratory studies Surgery and their prices (subject Specialist Consults: Referrals to change) are listed on the practice website. Medications Surgeons and Specialists will be ordered in the most cost-effective manner possible for the Patient. When we dispense medications in Pricing for all outside specialty referrals is determined by the office these medications will be made available to the patient at wholesale costorganization you are being referred to. Examples of commonly dispensed medications and their prices (subject to change) are listed on the practice website. Pathology studies (most commonly skin biopsies) will be ordered in the most economical manner possible. Anticipated prices for these studies (subject to change) are listed on the Practice website. Radiology studies will be ordered in the most cost-effective manner possible for the Patient. Commonly ordered radiologic studies and prices (subject to change) are listed on the website. Surgery and specialist consults will be ordered in the most cost-effective manner possible for the Patient. Gynecological (Well Woman) exams are done at no additional cost. The anticipated cost of the pap smear (subject to change) will be listed on the website. Vaccinations: Vaccinations are NOT offered in our office at this time due to the cost prohibitive nature of stocking a limited supply. We will make an effort to help you obtain needed vaccinations else xxxx elsewhere in the most cost-effective manner possible. Hospital Services: Hospital Services are NOT covered provided by our membership planthe Practice, and due to mandatory “on call” duties required at local institutions hospital rules and regulations, we have elected NOT to obtain formal hospital admission privileges for direct care at this time. Obstetric Virtual Visits (Phone Visit and Televideo Visit): Practice may offer televideo and phone virtual visits to Patients. These visits typically are offered to Patients who have a minor condition that can be diagnosed with reasonable certainty without a face-to-face visit and to Patients who have had a recent visit which generated multiple lab abnormalities requiring further Provider consultation. This form of visit is offered by Provider discretion as a convenience to Patients where an office visit would normally be required. Virtual visit fees are included in the Monthly Periodic Fee. Other Services: Practice may add additional Services in the future. These will be posted on our website. Patient Name Patient (Guardian) Signature Date (MM/DD/YYYY) RECEIPT OF NOTICE OF PRIVACY PRACTICES / ELECTRONIC COMMUNICATION / DISCLOSURE OF PHI / MESSAGES I, , have received a copy of Anovia Health, SC “Notice of Privacy Practices”. Patient’s Name Patient (Guardian) Signature Date (MM/DD/YYYY) I authorize Anovia Health, SC to send email or text which may include unencrypted protected health information. (Providing us with authorization to email and text you will allow Anovia Health, SC to exchange information with you more efficiently and will benefit you as a patient. At the same time, we recognize that email and text messaging are NOT covered not a completely secure means of communication. You are not required to authorize the use of email and text messages and a decision to not authorize electronic communication will not affect your health care in any way. We have taken considerable effort to protect the personal health information of our patients and recommend that all patients provide us with this authorization so that we can more efficiently communicate with them.) Name of Patient Patient (Guardian)Signature Date (MM/DD/YYYY) Our Practice takes Patient confidentiality and privacy very seriously but understands that certain Patients may wish for our Practice to disclose their “Protected Health Information” (PHI) to certain friends or family members to improve efficiency and delivery of health care Services. I authorize Anovia Health, SC to disclose my PHI (any information related to my care) to the following persons for the purpose of improving the delivery of healthcare Services to me. Name of Person: Relationship to Patient: Name of Person: Relationship to Patient: Phone #: Phone #: This authorization will remain in effect until I provide signed written notice to the Practice terminating this authorization. I do not have to sign this authorization in order to receive treatment from Anovia Health, SC. In fact, I have the right to refuse to sign this authorization. Refusal to sign this authorization will not affect my care in any way. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by our membership plan.the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to Xxx Xxxxxxxx, Box 230, 0000 X. Xxxxxxx Ave. Green Bay, WI 54301 ph: (920) 310-8920 Name of Patient Patient (Guardian) Signature Date (MM/DD/YYYY) I authorize Anovia Health, SC to leave messages containing Protected Health Information on my answering machine/answering service/voicemail . Patient Signature Our practice may offer a virtual visit in place of a face to face visit for certain conditions that can safely be evaluated and treated either by phone or using telemedicine such as a televideo visit. I consent to participation in telemedicine visits provided by Anovia Health, SC. Name of Patient Patient (Guardian) Signature Date (MM/DD/YYYY)
Appears in 1 contract
Samples: Membership Patient Agreement
Acceptance of Patients. We reserve the right to accept or decline patients based upon our capability to appropriately handle the patient’s primary care needs. We may decline new patients pursuant to the guidelines proffered in Section 6 (Term), because the PhysicianNurse Practitioner’s panel of patients is fullfull (capped at 1,200 patients or fewer), or because the patient requires medical care not within the PhysicianNurse Practitioner’s scope of services. Appendix 2 OC Sports and Wellness - Itemized Fees Ongoing Primary Care is included with the Periodic Fee described in Appendix 1. Please see a list of some of the chronic conditions we routinely treat on the Practice website (subject to change). There are no itemized fees for office visits unless the patient has more than fifteen (15) scheduled in-office visits in a calendar yearvisits. In-Office Procedures we are generally comfortable performing the procedures are listed on the Practice website. These are typically available at no additional cost unless otherwise designated, and these are also subject to change. Laboratory Studies will be drawn in the office or lab center at no additional charge and the Patient will be charged according to the direct price a discounted rate we have negotiated with the lab. An example of common laboratory studies and their prices (subject to change) are listed on the practice website. Medications will be ordered in the most cost-cost effective manner possible for the Patient. When we dispense medications in the office these medications will be made available to the patient Patient at wholesale cost. Examples of commonly dispensed medications and their prices (subject to change) are listed on the practice website. Pathology studies (most commonly skin biopsies) will be ordered in the most economical manner possible. Anticipated prices for these studies (subject to change) are listed on discounted at rate negotiated with the Practice websitelab. Radiology studies will be ordered in rate negotiated with the most cost-effective manner possible for the Patient. Commonly ordered radiologic studies and prices (subject to change) are listed on the websitelab. Surgery and specialist consults will be ordered in the most cost-cost effective manner possible for the Patient. Gynecological (Well Woman) exams are done at no additional cost. The anticipated cost of the pap smear (subject to change) will be listed on the website. Vaccinations are NOT offered in our office at this time due to the cost prohibitive nature of stocking a limited supply. We will make an effort to help you obtain needed vaccinations else xxxx elsewhere in the most cost-cost effective manner possible. Hospital Services are NOT covered by our membership plan. If you need to be hospitalized, you will be under the care of a Hospitalist. We will work collaboratively with your Hospitalist and due to mandatory “on call” duties required at local institutions we have elected NOT to obtain formal hospital admission privileges at this timecoordinate your care following discharge from the hospital. Obstetric Services are NOT covered by our membership plan.Signed: Date
Appears in 1 contract
Samples: Patient Membership Agreement
