Common use of Specialist Coordination Clause in Contracts

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 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 The physician shall coordinate as best as possible given with the constraints in interoperability in the current healthcare system with Patient's medical specialists to whom Patient is referred to and clinicians and shall assist the Patient in obtaining specialty carecare as needed. The Patient understands that fees paid under this Agreement do not include and do not cover specialist’s 's fees or fees due to any medical professional other than the CLINIC PhysicianPractice physician. Fees as set out in Appendix C shall apply to the following Patient(sTHE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING PATIENT(S)*. THE PARENT OR GUARDIAN, who by signing this agreement certify that they have readBY SIGNING THIS APPENDIX B, understand, and agree to the terms and conditions set forth in the KANSAS CITY DIRECT PRIMARY CARE CERTIFIES THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT. CHILD/CHILDREN TO WHOM THIS AGREEMENT APPLIES: 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 Name Date of Birth Name Date of Birth Name Date of Birth Name Date of Birth Patient Patient Patient Patient Patient PARENT OR GUARDIAN: (MM/DD/YYYYProvide email address only if you agree to Email communication) Age Street Address City, State, Zip Home Phone Preferred Contact Number: Cell Phone Preferred email I consent Phone: Email: Check YES/NO where indicated only if you agree to receiving communications from text message communication. Your signature indicates acceptance of the clinic terms of the Patient Agreement DO YOU AGREE TO TEXT AND EMAIL MESSAGE COMMUNICATION REGARDING THE HEALTH CARE CONCERNS OF THE ABOVE-NAMED CHILDREN? (CHECK ONE) ◻YES ◻NO Signature: Date: Printed Name: Relationship to Patient(s): Appendix C MEMBERSHIP ITEMIZATION Annual Membership Fee $5950 for children under 2 years old $4950 for children over 2 years old This includes all services listed in Appendix A as well as in-house labs and unlimited office visits, text messaging, video conferences and phone calls with 24/7 access 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 Emailproviders. Discounts