Common Contracts
1 similar Patient Membership Agreement contracts
Patient Membership Agreement Medicare Beneficiary AddendumPatient Membership Agreement • September 10th, 2018
This agreement is between Dr. Erin Kershisnik or Dr. Jennifer Vazquez-Bryan ("Physician"), whose principal place of business is Vantage Physicians, 3703 Ensign Road Suite 10A, Olympia, WA 98506 and patient _________________________________________________ ("Patient"), who resides at _______________________________________________________ and is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997.
