Authorization for Treatment and Financial Agreement - Concierge Medicine

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Authorization for Medical Treatment

I, the undersigned, consent to medical treatment, diagnostic procedures, and medical services deemed necessary by [PRACTICE NAME] and its healthcare providers. I understand that:

• This practice operates under a concierge medicine model
• My annual membership fee covers enhanced access and services as outlined in the membership agreement
• Additional medical services may incur separate charges
• I have the right to discuss any treatment plan with my physician

Financial Agreement

Annual Membership Fee

• I agree to pay the annual membership fee of $______
• I understand this fee is due on _______ of each year
• The fee is non-refundable and non-transferable

Additional Charges

• Regular office visits and medical services will be billed to insurance when applicable
• I am responsible for any copayments, deductibles, or non-covered services
• Laboratory tests, imaging studies, and specialist referrals are not included in the membership fee

Communication Consent

I authorize [PRACTICE NAME] to:

• Contact me via phone, email, or text message
• Leave detailed messages regarding appointments and test results
• Provide me with access to the patient portal

Acknowledgment

I have read and understand this authorization. I acknowledge that my questions have been answered to my satisfaction.

Patient Signature: _________________ Date: _____________

Physician Signature: _______________ Date: _____________