Equilibrium^2 Holistic Health, PLLC: Provider-Patient AgreementProvider-Patient Agreement • November 5th, 2020
This Agreement is entered into by and between Equilibrium^2 Holistic Health, PLLC (“Eq2”), a Texas Professional Association, Ryan Fowler, MD (“Dr. Fowler”) and Kelli Dudley, FNP-C (“Kelli Dudley”), and the undersigned patient (“Member”). Eq2 is a Direct Primary Care medical practice. Dr. Fowler and Kelli Dudley are the owners and primary providers of Eq2. Dr. Fowler and Kelli Dudley practice family medicine and deliver care on behalf of Eq2 at 6270 W. Adams, Temple, Texas 76502, and also provides care via electronic communication and home visits. In exchange for the fees set out in this Agreement, Dr. Fowler and Kelli Dudley at Eq2 agree to provide Member the services set forth below. This agreement is entered by mutual voluntary consent.
ContractProvider-Patient Agreement • January 21st, 2020
Welcome to our practice. This document (the Agreement) contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is provided with this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them careful
254)228-0588 (O)Provider-Patient Agreement • February 25th, 2022
This Agreement is entered into by and between Balance Integrative & Infusion, LLC (“Balance Integrative”), a Texas Professional Association and Kelli Dudley, APRN, FNP- C (“Kelli Dudley”), and the undersigned patient (“Member”). Balance Integrative is a Direct Primary Care medical practice. Kelli Dudley is the owner and primary provider. Kelli Dudley practices family medicine and delivers care on behalf of Balance Integrative & Infusion at 6208 W Adams, Temple, Texas 76502, and also provides care via electronic communication and home visits. In exchange for the fees set out in this Agreement, Kelli Dudley at Balance Integrative and Infusion, LLC agree to provide Member the services set forth below. This agreement is entered into by mutual voluntary consent.
IntroductionProvider-Patient Agreement • June 2nd, 2020
This Agreement is entered into by and between Equilibrium^2 Holistic Health, PLLC (“Eq2”), a Texas Professional Association, Ryan Fowler, MD (“Dr. Fowler”) and Kelli Dudley, APRN, FNP-C (“Kelli Dudley”), and the undersigned patient (“Member”). Eq2 is a Direct Primary Care medical practice. Dr. Fowler and Kelli Dudley are the owners and primary providers of Eq2. Dr. Fowler and Kelli Dudley practice family medicine and deliver care on behalf of Eq2 at 2027 S. 61st St., Ste. 109, Temple, Texas 76504, and also provides care via electronic communication and home visits. In exchange for the fees set out in this Agreement, Dr. Fowler and Kelli Dudley at Eq2 agree to provide Member the services set forth below. This agreement is entered into by mutual voluntary consent.
