Common use of Specialists Coordination Clause in Contracts

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. PATIENT ENROLLMENT 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 Xxxxxx Xxxxxxx, Xxxx, Xxxxx, Xxx Home Phone Cell Phone Do you agree to text message communication? YES NO Individual Membership $_125.00__ per month One-time Non-refundable Enrollment Fee $_100.00__ Should Patient’s membership lapse or be terminated, and Patient later wishes to re-enroll, Patient will be accepted on a space available basis only, subject to a $250.00 re-activation fee. Patient Fees $_125.00__ Enrollment Fees $_100.00__ Total Amount Due $_225.00__ Total Monthly Amount Due $_125.00__ Individual Membership $_375.00__ per quarter (3 months) One-time Non-refundable Enrollment Fee $_100.00__ Should Patient’s membership lapse or be terminated, and Patient later wishes to re-enroll, Patient will be accepted on a space available basis only, subject to a $250.00 re-activation fee. Patient Fees $_375.00__ Enrollment Fees $_100.00__ Total Amount Due $_475.00__ Total Quarterly Amount Due $_375.00__ This agreement (Agreement) is entered into by and between Mobile Medicine, PLLC, and Xxxxxx Xxxx, MD (Provider), whose principal address is, 0000 Xxxx Xxxxxxxx Xxxxx, Xxxxx 0, Xxxxxxxxxx, Xxxxxxx 00000, and _____________________, a beneficiary enrolled in Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997 (“Beneficiary”), who resides at _____________________________________________________________________. The Practice and Provider have informed Patient that Provider has opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.

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. PATIENT ENROLLMENT * Circle 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 belowbelow (or as parent or legal guardian), (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 Xxxxxx XxxxxxxStreet Address City, XxxxState, Xxxxx, Xxx Zip Home Phone Cell Phone Email Signature: Date Home Phone Cell Phone Email Do you agree to text message communication? YES NO (Circle one) Signature: Date Print Name Date of Birth (MM/DD/YYYY) Print Name Date of Birth (MM/DD/YYYY) Print Name Date of Birth (MM/DD/YYYY) Signature parent or guardian _ Date _ RELATIONSHIP: Individual Membership $_125.00__ $ 75 per month One-time Family Membership* $250 per month *2 Adults and 2 Dependents <26 years of age ) Non-refundable Enrollment Fee one-time enrollment fee $ 75. Individual $_100.00__ Should Patient’s membership lapse or be terminated, and 150 Family Patient later wishes to re-enroll, 1 $ Patient will be accepted on a space available basis only, subject to a $250.00 re-activation fee. Patient Fees $_125.00__ 2 Additional Patients Enrollment Fees $_100.00__ TOTAL AMOUNT DUE $ Total Amount Due $_225.00__ Total Continuing Monthly Amount Due $_125.00__ Individual Membership $_375.00__ per quarter (3 months) One-time Non-refundable Enrollment Fee $_100.00__ Should Patient’s membership lapse or be terminated, and Patient later wishes to re-enroll, Patient will be accepted on a space available basis only, subject to a $250.00 re-activation fee. Patient Fees $_375.00__ Enrollment Fees $_100.00__ Total Amount Due $_475.00__ Total Quarterly Amount Due $_375.00__ $ This agreement (Agreement) is entered into by and between Mobile MedicineEnvision Health LLC , PLLCXxxxxxxx X. Xxx, and Xxxxxx Xxxx, MD (ProviderDO(Provider), whose principal address is, 0000 000 Xxxxx Xxxx Xxxxxxxx XxxxxXxxxxx, Xxxxx 00X, XxxxxxxxxxXxxxx Xxxxx, Xxxxxxx 00000, and _____________________, a beneficiary enrolled in Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997 (“Beneficiary”), who resides at _____________________________________________________________________. The Practice and Provider have informed Patient that Provider has opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.,

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. PATIENT ENROLLMENT * Circle 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 belowbelow (or as parent or legal guardian), (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 Xxxxxx XxxxxxxStreet Address City, XxxxState, Xxxxx, Xxx Zip Home Phone Cell Phone Email Signature: Date Home Phone Cell Phone Email Do you agree to text message communication? YES NO (Circle one) Signature: Date Print Name Date of Birth (MM/DD/YYYY) Print Name Date of Birth (MM/DD/YYYY) Print Name Date of Birth (MM/DD/YYYY) Signature parent or guardian _ Date _ RELATIONSHIP: Individual Membership $_125.00__ >26yo $ 85 per month One-time Pediatric patient with parent/guardian <26 yo $ 65 per month Non-refundable Enrollment Fee one-time enrollment fee $ 75. Individual $_100.00__ Should Patient’s membership lapse or be terminated, and 150 Family Patient later wishes to re-enroll, 1 $ Patient will be accepted on a space available basis only, subject to a $250.00 re-activation fee. Patient Fees $_125.00__ 2 Additional Patients Enrollment Fees $_100.00__ TOTAL AMOUNT DUE $ Total Amount Due $_225.00__ Total Continuing Monthly Amount Due $_125.00__ Individual Membership $_375.00__ per quarter (3 months) One-time Non-refundable Enrollment Fee $_100.00__ Should Patient’s membership lapse or be terminated, and Patient later wishes to re-enroll, Patient will be accepted on a space available basis only, subject to a $250.00 re-activation fee. Patient Fees $_375.00__ Enrollment Fees $_100.00__ Total Amount Due $_475.00__ Total Quarterly Amount Due $_375.00__ $ This agreement (Agreement) is entered into by and between Mobile MedicineEnvision Health LLC , PLLCXxxxxxxx X. Xxx, and Xxxxxx Xxxx, MD (ProviderDO(Provider), whose principal address is, 0000 Xxxx Xxxxxxxx Xxxxx1501 S. Xxxxx Xxxxxx, Xxxxx 0000, XxxxxxxxxxXxxxx Xxxxx, Xxxxxxx 00000, and _____________________, a beneficiary enrolled in Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997 (“Beneficiary”), who resides at _____________________________________________________________________. The Practice and Provider have informed Patient that Provider has opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.,

Specialists Coordination. PRACTICE and Physician shall coordinate with Patient’s medical specialists to assure continuity of care, and if necessary, shall whom Patient is referred to assist Patient in obtaining a referral for specialty care. Patient understands that monthly fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any outside medical professionalprofessional other than the PRACTICE Physician. These are the patient’s responsibility but Patient may submit such charges to insurance. PATIENT ENROLLMENT The fees Monthly fees, as set out in the attached Appendix C, shall apply to the following Patient(s): Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Preferred email Spouse Name Date of Birth (MM/DD/YYYY) Age Home Phone Work Phone Cell Phone Preferred email Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method (circle one), who by signing below, (or) as Parent or Legal Guardian * Credit Card Debit Card Bank Draft I certify that they I have read read, understand, and agree to the terms and conditions set forth in this Medical Agreement Form. Signature: _ 0-19 years of this Agreement: Patient Name Date age $10 per month* 0-19 years of Birth Email Xxxxxx Xxxxxxx, Xxxx, Xxxxx, Xxx Home Phone Cell Phone Do you agree to text message communication? YES NO Individual Membership age $_125.00__ 50 per month** 20-49 years of age $50 per month One50-time 64 years of age $75 per month 65+ years of age $100 per month Enrollment Fee $150 per person, not to exceed $300 per household*** *With the enrollment of at least one adult member. **Without a fully enrolled adult member. ***Non-refundable Enrollment Fee $_100.00__ fee. Should Patient’s your membership lapse or be terminated, and Patient later wishes the enrollment fee must be paid again for membership to re-enroll, Patient will be accepted on a space available basis only, subject to a $250.00 re-activation feebecome active. Patient Fees $_125.00__ Enrollment Fees $_100.00__ Total Amount Due $_225.00__ Total Monthly Amount Due $_125.00__ Individual Membership $_375.00__ per quarter (3 months) One-time Non-refundable Enrollment Fee $_100.00__ Should Patient’s membership lapse or be terminated, and 1 $ Patient later wishes to re-enroll, Patient will be accepted on a space available basis only, subject to a $250.00 re-activation fee. Patient Fees $_375.00__ Enrollment Fees $_100.00__ Total Amount Due $_475.00__ Total Quarterly Amount Due $_375.00__ 2 Additional Patients TOTAL RATE $ This agreement (Agreement) is entered into by and between Mobile MedicineOctagram Direct Primary Care, PLLCa Pennsylvania Professional Limited Liability Company, and Xx. Xxxxx Xxxxxx Xxxx, MD (ProviderPhysician), whose principal address is, 0000 Xxxx Xxxxxxxx Xxxxxis 000 Xxxxxx Xxxxxx Xxxx, Xxxxx 0000X, XxxxxxxxxxXxxxxxx, Xxxxxxx Xxxxxxxxxxxx 00000, and _____________________, a beneficiary enrolled in Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997 (“Beneficiary”), who resides at _____________________________________________________________________, , PA . The Practice and Provider have Physician has informed Patient that Provider Physician has opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.

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. PATIENT ENROLLMENT * Circle 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 belowbelow (or as parent or legal guardian), (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 Xxxxxx XxxxxxxStreet Address City, XxxxState, Xxxxx, Xxx Zip Home Phone Cell Phone Email Signature: Date Home Phone Cell Phone Email Do you agree to text message communication? YES NO (Circle one) Signature: Date Print Name Date of Birth (MM/DD/YYYY) Print Name Date of Birth (MM/DD/YYYY) Print Name Date of Birth (MM/DD/YYYY) Signature parent or guardian _ Date _ RELATIONSHIP: Individual Membership $_125.00__ $ 75 per month One-time Family Membership* $250 per month *2 Adults and 2 Dependents <26 years of age Non-refundable Enrollment Fee one-time enrollment fee $ 75. Individual $_100.00__ Should Patient’s membership lapse or be terminated, and 150 Family Patient later wishes to re-enroll, 1 $ Patient will be accepted on a space available basis only, subject to a $250.00 re-activation fee. Patient Fees $_125.00__ 2 Additional Patients Enrollment Fees $_100.00__ TOTAL AMOUNT DUE $ Total Amount Due $_225.00__ Total Continuing Monthly Amount Due $_125.00__ Individual Membership $_375.00__ per quarter (3 months) One-time Non-refundable Enrollment Fee $_100.00__ Should Patient’s membership lapse or be terminated, and Patient later wishes to re-enroll, Patient will be accepted on a space available basis only, subject to a $250.00 re-activation fee. Patient Fees $_375.00__ Enrollment Fees $_100.00__ Total Amount Due $_475.00__ Total Quarterly Amount Due $_375.00__ $ This agreement (Agreement) is entered into by and between Mobile MedicineEnvision Health LLC , PLLCXxxxxxxx X. Xxx, and Xxxxxx Xxxx, MD (ProviderDO(Provider), whose principal address is, 0000 Xxxx Xxxxxxxx Xxxxx1501 S. Xxxxx Xxxxxx, Xxxxx 0000, XxxxxxxxxxXxxxx Xxxxx, Xxxxxxx 00000, and _____________________, a beneficiary enrolled in Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997 (“Beneficiary”), who resides at _____________________________________________________________________. The Practice and Provider have informed Patient that Provider has opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.,