Concierge Medicine Patient Informed Consent Agreement

I. Introduction

This Informed Consent Agreement ("Agreement") is entered into on [DATE] between:

• Practice Name: [PRACTICE NAME]
• Physician: [PHYSICIAN NAME], MD
• Patient: [PATIENT NAME]

II. Services and Benefits

1. Enhanced Access

   • Direct physician cell phone access
   • Same-day or next-day appointments
   • Extended appointment times (minimum 30 minutes)
   • 24/7 availability for urgent medical concerns

2. Comprehensive Care

   • Annual executive physical examination
   • Preventive care services
   • Care coordination with specialists
   • Personalized wellness planning

III. Financial Terms

1. Annual Membership Fee: $[AMOUNT]

   • Payment due: [TERMS]
   • Renewal date: [DATE]

2. Insurance and Medicare

   • This agreement does not replace health insurance
   • Standard medical services will be billed to insurance/Medicare
   • Membership fee covers only non-covered concierge services

IV. Patient Acknowledgments

I understand and acknowledge that:

• This agreement is not a substitute for health insurance
• The annual fee is not covered by insurance or Medicare
• I may terminate this agreement with 30 days written notice
• Medical records will be maintained in accordance with law

V. Signatures

Patient Signature: _______________ Date: _______________

Physician Signature: _____________ Date: _______________

VI. Contact Information

Practice Address: [ADDRESS] Phone: [PHONE] Email: [EMAIL]