Article 1: Parties and Services
This agreement is made between:
-
Practice/Physician: [Practice Name] ("Provider")
-
Patient: [Patient Name] ("Patient")
1.1 Services Included
- 24/7 direct physician access via phone/text
- Same-day or next-day appointments
- Extended appointment times (minimum 30 minutes)
- Direct cell phone access to physician
- Annual comprehensive physical examination
- Preventive care services
- Care coordination with specialists
1.2 Services Not Included
- Specialty care services
- Hospital charges
- Laboratory fees
- Prescription medications
- Medical procedures performed outside the practice
Article 2: Financial Terms
2.1 Annual Membership Fee
- Amount: $[Amount]/year
- Payment Schedule: [Monthly/Quarterly/Annual]
- Payment Method: [Accepted Methods]
2.2 Insurance and Billing
- Patient remains responsible for maintaining health insurance
- Practice will provide documentation for insurance reimbursement
- Membership fee is not billable to insurance
Article 3: Term and Termination
3.1 Duration
- Initial term: 12 months
- Automatic renewal unless terminated
3.2 Termination
- 30-day written notice required
- Pro-rated refund of prepaid fees
- Practice reserves right to terminate for cause
Article 4: Privacy and Communications
4.1 HIPAA Compliance
- Practice maintains HIPAA compliance
- Electronic communications security protocols
4.2 Preferred Communication
- Patient preferred contact: [Method]
- Emergency contact procedures
Signatures
Physician: _________________ Date: _______
Patient: ___________________ Date: _______