Patient Registration Agreement Sample Contracts

PATIENT REGISTRATION AGREEMENT (ADULT)

Patient Registration Agreement • July 10th, 2022

• Contract Type
  Patient Registration Agreement
• Filed
  July 10th, 2022

• I/We understand that the initial meeting is for the purpose of evaluation and to determine if a working relationship with Dr. Segal can be established.

PATIENT REGISTRATION AGREEMENT

Patient Registration Agreement • November 13th, 2017 • Pennsylvania

• Contract Type
  Patient Registration Agreement
• Filed
  November 13th, 2017
• Jurisdiction
  Pennsylvania

Please read the following Washington Health System Patient Registration Agreement (“Registration Agreement”) carefully before deciding whether to register for access to the non-public portions of this Washington Health System website ("Portal") or register use of the Washington Health System mobile app (“App”), which are both provided to you by Washington Health System (“WHS” or “we”) for the benefit of the Participating Providers (each, a “Provider”). The Portal and App are collectively referred to below as the “Platform”. This Platform will permit you to request and access certain telemedicine services and consultations (“Services”) as provided by the Providers, together with your identifiable health information whether submitted by you or generated as a result of your use of the Services ("Health Information").

WELLSPAN ONLINE URGENTCARE―PATIENT REGISTRATION AGREEMENT

Patient Registration Agreement • September 5th, 2017 • Pennsylvania

• Contract Type
  Patient Registration Agreement
• Filed
  September 5th, 2017
• Jurisdiction
  Pennsylvania

Please read the following WellSpan Health Patient Registration Agreement (“Agreement”) carefully before deciding whether to register for access to the non-public portions of this WellSpan Health website ("Portal") or register use of the WellSpan Health mobile app (“App”), which are both provided to you by WellSpan Health (“COMPANY”) for the benefit of WellSpan Medical Group Providers (each, a “Provider”). The Portal and App are collectively referred to below as the “Platform”. This Platform will permit you to request and access certain behavioral health and other medical consultation services (“Services”) as provided by the Providers, together with your identifiable health information whether submitted by you or generated as a result of your use of the Services ("Health Information").