Common use of Specialists Coordination Clause in Contracts

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. 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: Print Patient Name Date of Birth Street Address City, State, Zip Cell Phone Alternate Number Email I Agree to Text Communication: (circle one below) ● Yes ● No Printed Name: Relationship to Patient: Patient Name Date of Birth Cell Phone Alternate Number Email I agree to Text Communication: (circle one below) ● YES ● NO Printed Name: Relationship to Patient: Patient Name Date of Birth Cell Phone Alternate Number Email Agree to Text Communication: (circle one below) ● YES ● NO Printed Name: Relationship to Patient: Patient Name Date of Birth Cell Phone Alternate Number Email I agree to Text Communication: (circle one below) ● YES ● NO Printed Name: Relationship to Patient:

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. 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: Print Patient Name Date of Birth Street Address City, State, Zip Cell Phone Alternate Number Email I Agree to Text Communication: (circle check one below) ● 🞎 Yes ● 🞎 No Printed Name: Relationship to Patient: Patient Name Date of Birth Cell Phone Alternate Number Email I agree to Text Communication: (circle check one below) ● 🞎 YES ● 🞎 NO Printed Name: Relationship to Patient: Patient Name Date of Birth Cell Phone Alternate Number Email Agree to Text Communication: (circle check one below) ● 🞎 YES ● 🞎 NO Printed Name: Relationship to Patient: Patient Name Date of Birth Cell Phone Alternate Number Email I agree to Text Communication: (circle check one below) ● 🞎 YES ● 🞎 NO Printed Name: Relationship to Patient:

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. 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: Print Patient Name Date of Birth Street Address City, State, Zip Cell Phone Alternate Number Email I Agree to Text Communication: (circle check one below) ● 🞎 Yes ● 🞎 No Printed Name: Relationship to Patient: Patient Name Date of Birth Cell Phone Alternate Number Email I agree to Text Communication: (circle check one below) ● 🞎 YES ● 🞎 NO Printed Name: Relationship to Patient: Patient Name Date of Birth Cell Phone Alternate Number Email Agree to Text Communication: (circle check one below) ● 🞎 YES ● 🞎 NO Printed Name: Relationship to Patient: Patient Name Date of Birth Cell Phone Alternate Number Email I agree to Text Communication: (circle check one below) ● 🞎 YES ● 🞎 NO Printed Name: Relationship to Patient:: There is a one time, nonrefundable enrollment fee of $60.