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.
Specialist Coordination. CLINIC and Dentist shall coordinate with dental 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 Dentist.
Specialist Coordination. 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 Physician. Fees as set out in Appendix C shall apply to the following Patient(s)*, 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 Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Cell Phone Preferred email I consent to receiving communications from the clinic to the above email address and/or cell number [ ] YES or [ ] NO (Initial) Spouse’s Name Date of Birth (MM/DD/YYYY) Age Spouse’s Cell Phone Spouse’s Preferred Email I consent to receiving communications from the clinic to the above email address and/or cell number [ ] YES or [ ] NO (Initial) Name of Legal Guardian(s): Relationship: I, 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 cell number(s) and/or email address(es) provided above [ ] YES or [ ] NO (Initial) Child’s Name Date of Birth (MM/DD/YYYY) Age Child’s Cell Phone Child’s Preferred Email
Specialist Coordination. Clinic and Physician shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this 0-17 years of age: $20 per month (with the enrollment of at least one adult member) 18+ years of age: $70 per month Family Max: $180 per month 18+ years of age: $250 per month Individual: $50 Family max: $150
Specialist Coordination. Together Health and the Clinician shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. The 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 Together Health’s Clinician. Enrollment Fee* $50 individual plan and $75 for family plan 8-71+ years of age: $41 per month
Specialist Coordination. The provider shall coordinate care with medical specialists and other practitioners to whom the Patient needs referral. The Patient understands that fees paid under this Agreement do not include specialist's fees or fees due to any medical professional other than the Practice staff. CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING PATIENT(S), WHO BY SIGNING BELOW (OR AS LEGAL REPRESENTATIVE), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Total Adult: Total Child: Print Patient Name Date of Birth Street Address City, State, Zip Cell Phone Alternate Number Email I Agree to Text Communication: (check one below) ◻ Yes ◻ No Printed Name: Patient Name Date of Birth Cell Phone Alternate Number Email Patient over 18? ◻ YES ◻ NO If no Minor Consent Signed? ◻ YES ◻ NO I agree to Text Communication: (check one below) ◻ YES ◻ NO Printed Name: Relationship to Patient: Patient Name Date of Birth Patient over 18? ◻ YES ◻ NO If no Minor Consent Signed? ◻ YES ◻ NO Agree to Text Communication: (check one below) ◻ YES ◻ NO Printed Name: Relationship to Patient: Patient Name Date of Birth Patient over 18? ◻ YES ◻ NO If no Minor Consent Signed? ◻ YES ◻ NO I agree to Text Communication: (check one below) ◻ YES ◻ NO Printed Name: Relationship to Patient:
Specialist Coordination. Your provider shall coordinate treatment and care with Your medical specialists and shall assist with specialist referrals as requested and/or necessary. Your Membership Agreement does not include or cover specialist's fees or fees from any medical professional outside of the practice. All such fees are the personal responsibility of the Member.
