Published value rates Sample Clauses

Published value rates. There is no charge for these services under membership arrangement. These are published rates. Physical Exam: $500, Routine Office Visit: $300, Sick Visit: $150, Problem Visit: $300, Tele Visit: $200, Forms Completed: $100, Physician or nurse phone call for questions: $50 I authorize Adirondack Direct Primary Care to perform recurring monthly credit/debit card charges to the following card and any updated future card I provide. # exp / CVC If you want the Physician to be able to communicate with a family member or friend. I authorize Adirondack Direct Primary Care to release my medical and/or billing information to the following individual(s): Name: _ Relation: Phone: Name: _ Relation: Phone: Name: _ Relation: Phone: I authorize Adirondack Direct Primary Care to contact me and leave brief information messages at the following numbers(s): Home Work _ Cell _ The parties have signed this Patient Agreement the day and year first above written. I have read, understand and agree to the provisions in this Patient Agreement. Patient Printed Name DOB Patient Signature Date _ Date Xxxxxx X. Xxxxxx, MD Adirondack Direct Primary Care PLLC For patients covered by Medicare ONLY Xxxxxx X. Xxxxxx, MD Adirondack Direct Primary Care, PLLC 0 Xxxxxxxx Xxxxxx Glens Falls, NY 12801 xxx.xxxxxxxxxxxxxx.xxx Xxxx@xxxxxxxxxxxxxx.xxx P: 518-798-9401 F: 000-000-0000 PATIENT MEDICARE PRIVATE CONTRACT AGREEMENT ADIRONDACK DIRECT PRIMARY CARE, PLLC This agreement is entered into this day of , by and between Xxxxxx X. Xxxxxx (hereinafter called “physician”), whose principal medical office is located at 0 Xxxxxxxx Xxxxxx Glens Falls, NY 112801 and DOB / / (a patient enrolled in Medicare Part B, hereinafter called “patient”), who resides at .