Patient Membership Agreement Wellscape Direct MD, LLCPatient Membership Agreement • March 22nd, 2022 • Massachusetts
This is an Agreement between you, the Member, and Wellscape Direct MD, LLC, a Massachusetts limited liability company located at 30 Lancaster Street in Boston, Massachusetts. Wellscape Direct MD is a Direct Primary Care medical practice owned and run by Linnea A. Meyer, MD. In exchange for monthly fees paid by you, the Member, Wellscape Direct MD will provide the primary care medical services described in this Agreement.
PATIENT MEMBERSHIP AGREEMENT FORWARD FAMILY HEALTHCARE, LLCPatient Membership Agreement • December 27th, 2022 • Nebraska
This Patient Membership Agreement (this “Agreement”) is entered into as of the date of its execution, as indicated below (the “Effective Date”), by and between Forward Family Healthcare, LLC, a Nebraska limited liability company (the “Clinic”), and (the “Patient”).
CONCIERGE MEDICINE OF STUART, PA PATIENT MEMBERSHIP AGREEMENTPatient Membership Agreement • September 1st, 2022
This is an Agreement entered into and to be effective the day of 20 (the “Effective Date”), by and between the person signing below (the “Member” or “you”) and CONCIERGE MEDICINE OF STUART, PA, a Florida professional association, of 400 SE Osceola Street, Suite 1, Stuart, Florida 34994 (the “Practice”).
Dr Lori A Cohen Patient Membership AgreementPatient Membership Agreement • November 29th, 2021
The Practice provides traditional medical services to patients. You desire, in exchange for a fee indicated below, certain non-medical services or Amenities( the “Amenities”) from the Practice as part of and by virtue of this patient-membership agreement. The purpose of this agreement is to set forthe the terms and conditions of how the Amenities will be furnished to you by the Practice. You and the Practice therefore agree as follows.
Patient Membership Agreement)Patient Membership Agreement • October 9th, 2022
I, agree to all of the following terms and conditions of membership of Quality Control Delivery, a nonprofit mutual benefit corporation organized under the California Nonprofit Mutual Benefit Corporation Law (referred to as the “Collective“). I understand that this Agreement is required to join the Collective, and I promise to abide by its terms and conditions at all times during my tenure as a member of the Collective. In consideration of the processing of my application, and of the rights, privileges and benefits of membership in the Collective, and for other good and valuable consideration the receipt of which is hereby acknowledged, I enter into this Agreement as of the date set forth next to my signature.
PRESERVE HEALTH MD PATIENT MEMBERSHIP AGREEMENTPatient Membership Agreement • September 17th, 2020
This is Agreement and Schedules entered into and to be effective the __ day of _____________20__ (the “Effective Date”), by and between the person signing below (the “Member” or “You”) and ISPMD, LLC, doing business as PRESERVE HEALTH MD, a Florida limited liability company (the “Practice”).
Patient Membership Agreement Action Medicine, DPC, PCPatient Membership Agreement • September 13th, 2017
This is an Agreement between you, the Member, and Action Medicine, DPC, PC, “Action Medicine” a Massachusetts professional corporation located at 175 N Franklin St, Holbrook, Massachusetts. Action Medicine is a Direct Primary Care medical practice owned and run by Dr. Michael W. Tremblay. In exchange for monthly fees paid by you, the Member, Action Medicine will provide the services described in this Agreement.
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.
HUMMINGBIRD HEALTH, LLC PATIENT MEMBERSHIP AGREEMENTPatient Membership Agreement • January 3rd, 2023 • Florida
This Membership Agreement is a contract for medical services to be provided by Hummingbird Health, LLC, and is effective as of the last date entered below.
Patient Membership AgreementPatient Membership Agreement • August 3rd, 2020 • Ohio
(“Effective Date”) by and between MCGILLIGAN MD, INC, an Ohio corporation, located at 7529 State Road, Suite B, Cincinnati OH 45255 (the “Practice”) and , an individual residing at
PATIENT MEMBERSHIP AGREEMENT-Patient Membership Agreement • March 19th, 2019
Member name: DOB: Mailing address: Email: Primary Phone#: Secondary Phone#: Additional Family Members to be Included (list names & relationship):
ROBERT N. SCHNITZLER, MD, PA PATIENT MEMBERSHIP AGREEMENTPatient Membership Agreement • March 9th, 2020
This is an Agreement entered into and to be effective the (the “Effective Date”); by and between (the “Member” or “you”) and ROBERT N. SCHNITZLER, MD, a physician employed by ROBERT N. SCHNITZLER, MD, PA, a Texas professional association, of 8122 Datapoint, Suite 700, San Antonio, Texas 78229 (the “Practice”).
LITTLETON CONCIERGE MEDICINE, PLLC PATIENT MEMBERSHIP AGREEMENTPatient Membership Agreement • May 12th, 2016
Littleton provides primary care medical services to patients, and employs Jason Littleton, M.D. (the “Physician”) for the purpose of providing the services defined in this Agreement. You desire to receive, in exchange for a fee, certain medical services (“Medical Services”) and non-medical services (“Non- Medical Services”) (collectively the “Services”) from LCM as part of and by virtue of this Agreement. The purpose of this Agreement is to set forth the terms and conditions of how the Services will be furnished you by LCM. You and LCM therefore agree as follows:
Patient Membership AgreementPatient Membership Agreement • February 17th, 2022 • Georgia
This agreement is made effective on the date set forth on the signature page and is an agreement between, Erinn R. Harris MD, PC (“Harris Internal Medicine”) and the patient identified on the signature page (“you and/or member and/or patient”).
Patient Membership AgreementPatient Membership Agreement • May 31st, 2021
This is an Agreement between you, as a DaySpring Wellness “Member”, and our team here at DaySpring Integrative Wellness, SC, (“DaySpring”), as a professional Maine service corporation located at 1 North Street, Bath, Maine, 04530.
NORTH OKALOOSA FAMILY MEDICINE, PLLC PATIENT MEMBERSHIP AGREEMENTPatient Membership Agreement • February 6th, 2017 • Florida
This Membership Agreement is a contract for medical services to be provided by North Okaloosa Family Medicine, PLLC, and is effective as of the last date entered below.
PATIENT MEMBERSHIP AGREEMENT SPEAR DIRECT CARE, PLLCPatient Membership Agreement • April 28th, 2020 • Idaho
This is an Agreement entered into on , 20 , between Spear Direct Care, PLLC, an Idaho professional limited liability company (“Clinic”, “Us” or “We”), and
PATIENT MEMBERSHIP AGREEMENTPatient Membership Agreement • January 29th, 2024
Enlightened Family Medicine, LLC (“Practice”) and , (“Patient”) enter into this Direct Primary Care Membership Agreement (“Membership Agreement”) with the Effective Date as stated in Section 1(c) for Patient to become a member of Practice’s Direct Primary Care Program. Practice and Patient are referred to herein collectively as the “Parties.”
Patient Membership AgreementPatient Membership Agreement • June 22nd, 2018 • Georgia
This agreement is made effective on the date set forth on the signature page and is an agreement between, Erinn R. Harris MD, PC (“Harris Internal Medicine”) and the patient identified on the signature page (“you and/or member and/or patient”).
PATIENT MEMBERSHIP AGREEMENTPatient Membership Agreement • December 10th, 2020 • Colorado
Patient Membership AgreementPatient Membership Agreement • March 1st, 2021 • Florida
• This agreement is made effective on the date set forth on the signature page and is an agreement between, St Johns Direct Primary Care, LLC (herein referred to as SJDPC) and the Patient identified on the signature page (“you and /or member and /or patient”).
Pati nt r m nt anPatient Membership Agreement • February 21st, 2014
•I acknowledge and understand that the person listed above is voluntarily becoming a Member of The Doc Shoppe, PLLC and that this agreement is non-transferable.
DIRECT SPECIALTY CARE PATIENT MEMBERSHIP AGREEMENTPatient Membership Agreement • July 5th, 2022
Welcome to Morning Star Osteoporosis and Metabolic Bone Disorders (“Practice”). We are glad to part of your healthcare team. Communication is at the center of our care, and this Patient Agreement (“Agreement”) explains how we will work together.
Patient Membership AgreementPatient Membership Agreement • May 21st, 2015
This agreement is between Dr. Erin Kershisnik and or Dr. Samantha Ritchie ("Physician"), whose principal place of business is Vantage Physicians,
MITCHELL MEDICAL GROUP OF NY, PC PATIENT MEMBERSHIP AGREEMENTPatient Membership Agreement • June 16th, 2020
Mitchell Medical Group provides medical services to patients, and employs Dean C. Mitchell, M.D. (the "Physician") for the purpose of providing the services defined in this Agreement. You desire to receive, in exchange for a fee, certain medical services ("Medical Services") and non-medical services (“Non-Medical Services") (collectively the "Services") from MMG as part of and by virtue of this Agreement. The purpose of this Agreement is to set forth the terms and conditions of how the Services will be furnished you by MMG. You and MMG therefore agree as follows:
Patient Membership AgreementPatient Membership Agreement • October 11th, 2021 • Georgia
● This agreement is made effective on the date set forth on the signature page and is an agreement between, Harris Internal Medicine, LLC, and the patient identified on the signature page (“you and/or member and/or patient”).
