Specialists Coordination. The physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals to outside specialty care. The Patient understands that fees paid under this Agreement do not include or cover specialist's fees or charges from any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patient. APPENDIX B Electronic Communications 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 MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient Name Date of Birth Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes �� No Signature: Patient 2 Patient Name Date of Birth Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 YES 🞎 NO Signature APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18-59 years of age $ 200 per month $ 60+ years of age $ 275 per month $ Total Monthly Membership Fee $ Enrollment Fee $150 per Member* (one time, non-refundable) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amount:
Specialists Coordination. The Physician shall coordinate with medical specialists to whom Patient is referred in order to assist Patient in obtaining specialty care. 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. These are the Patient’s responsibility.
Specialists Coordination. Physician shall coordinate with Patient’s medical specialists to assure continuity of care, and if necessary, shall assist in obtaining a referral for specialty care. Patient understands that monthly fees paid under this Agreement do not include specialist’s fees or fees due to any outside medical professional. These are the patient’s responsibility but Patient may submit such charges to insurance. APPENDIX B PATIENT ENROLLMENT * Click box for YES where indicated only if you agree to text message communication and 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 Parent or Legal Guardian certify that they have read and agree to the terms and conditions of this Agreement: Patient Name Date of Birth Email Street Address, City, State, Zip Home Phone Cell Phone Do you agree to text message communication? YES NO Signature of Patient / Guardian: Date: APPENDIX C
Specialists Coordination. Practice and dentist 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 fees or fees due to any medical professional other than Crafted Dentistry of Fort Mill staff. APPENDIX B PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual and monthly fees as set out in Appendix C shall apply to the following Patient(s), who by signing below agree to the terms and conditions of the Crafted Dentistry of Fort Mill Medical Agreement Form. *All patients must have a credit or debit card on file to cover the cost of membership & any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in this Medical Agreement Form. I further certify that I have received a copy of this form. APPENDIX C MEMBERSHIP PRICE Dental Membership Plan: First Member - $33/Month $349/Year Second Member- $30/Month $329/Year Perio Membership Plan: Individual - $50/Month $549/Year SIGNATURE Patient Signature Printed Name
Specialists Coordination. CLINIC and Provider 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 Provider. APPENDIX C FEE ITEMIZATION Single: Individual Member $75 per month Couple: Member + Spouse or Child $140 per month Family: Member + Spouse & Child(ren) $200 per month *Children must be under 25 years old. APPENDIX D
Specialists Coordination. Practice and dentist shall coordinate with medical specialists to whom the patient is referred to assist Patient in obtaining specialty care. Patients understand that fees paid under this Agreement do not include and do not cover specialist fees or fees due to any medical professional other than Xxxxxxxx Dental, LLC staff. APPENDIX B PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual and monthly fees as set out in Appendix C shall apply to the following Patient(s), who by signing below agree to the terms and conditions of the Xxxxxxxx Dental, LLC Medical Agreement Form. *All patients must have a credit or debit card on file to cover the cost of membership & any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in this Medical Agreement Form. I further certify that I have received a copy of this form. APPENDIX C MEMBERSHIP PRICE Basic Plan $300 yearly $25 monthly* VIP Plan $420 yearly $35 monthly* Perio Plan $540 yearly $45 monthly* *Monthly plans have a one-time set up fee of $149 SIGNATURE Patient Signature _ Printed Name
Specialists Coordination. CLINIC and DSC Provider shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Member 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 DSC Provider.
Specialists Coordination. Practice and dentist 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 fees or fees due to any medical professional other than Odon Family Dentistry staff. APPENDIX B PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual and monthly fees as set out in Appendix C shall apply to the following Patient(s), who by signing below agree to the terms and conditions of the Odon Family Dentistry Medical Agreement Form. *All patients must have a credit or debit card on file to cover the cost of membership & any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in this Medical Agreement Form. I further certify that I have received a copy of this form. APPENDIX C MEMBERSHIP PRICE Dental Membership Plan Adults - $399/Year or $38/Month Children - $349/Year or $33/Month Perio Membership Plan Individuals - $799/Year or $69/Month SIGNATURE Patient Signature Printed Name
Specialists Coordination. Practice and dentist 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 fees or fees due to any medical professional other than Orchard Dental SC/ dba WisconsinSmiles staff. APPENDIX B PATIENT ENROLLMENT – MEMBERSHIP AGREEMENT FORM Annual and monthly fees as set out in Appendix C shall apply to the following Patient(s), who by signing below agree to the terms and conditions of the Orchard Dental SC/ dba WisconsinSmiles Membership Agreement Form. *All patients must have a credit or debit card on file to cover the cost of membership & any incidentals not covered under the Agreement. APPENDIX C MEMBERSHIP PRICE Child 1-12 yrs. $25 one time signup fee $300 per year or $27 per month Adult 13 and above $25 one time signup fee $420 per year or $37 per month I certify that I have read, understand, and agree to the terms set forth in this Membership Agreement Form. I further certify that I have received a copy of this form. Member Date
Specialists Coordination. The physician 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. APPENDIX B MEMBER ROSTER* NAME RELATIONSHIP CONTACT NO. AGE Employee Spouse Child Child Child Employee Spouse Child Child Child Employee Spouse Child Child Child *Example Roster Only APPENDIX C FEE ITEMIZATION Monthly Membership Fees Employee $120/mo x members $ Dependent (spouse) $100/mo x members $ Dependent (children) $50/mo x members $ (8-18 yo) Total Monthly Membership Fee $ APPENDIX D
