Concierge Medicine Financial Agreement and Terms of Service

Patient Information

Name: _________________________
Date of Birth: __________________
Membership Start Date: __________

Annual Membership Terms

Fee Structure

• Annual Membership Fee: $________
• Payment Frequency: □ Annual □ Semi-Annual □ Quarterly
• Initial Registration Fee: $________ (one-time, non-refundable)

Services Included in Membership

1. 24/7 direct physician access
2. Same-day or next-day appointments
3. Extended visit times (minimum 30 minutes)
4. Direct phone and email communication
5. Coordinated specialist care
6. Annual comprehensive physical examination
7. Preventive care services as outlined in membership tier

Financial Responsibilities

• Member understands that the annual fee does not include:
  • Specialty care services
  • Hospital charges
  • Laboratory fees
  • Imaging services
  • Medications
  • Services not explicitly listed in membership agreement

Insurance and Medicare

1. Patient acknowledges that this agreement is not a substitute for health insurance
2. Practice □ does □ does not participate with Medicare
3. Patient agrees to maintain health insurance for services not covered by membership

Termination and Refund Policy

• 30-day written notice required for termination
• Pro-rated refund available for annual payments
• No refund for partial months

Acknowledgment

I have read and understand the financial policies outlined above and agree to comply with these terms.

Patient Signature: ___________________ Date: ________

Physician Signature: _________________ Date: ________