Concierge Medicine Patient Membership Agreement

Agreement Details

This Membership Agreement ("Agreement") is made between:

[Practice Name] ("Practice") [Address] [Phone, Email]

and

Patient Name: _________________________

1. Services Provided

1.1 Core Membership Benefits

• 24/7 direct physician access via phone and secure messaging
• Same-day or next-day appointments
• Extended appointment times (minimum 30 minutes)
• Annual comprehensive physical examination
• Preventive care coordination
• Direct cell phone access to physician

1.2 Additional Services

• House calls (as medically appropriate)
• Coordination with specialists
• Virtual consultations
• Wellness planning

2. Membership Terms

2.1 Duration

This agreement is valid for 12 months from the effective date.

2.2 Fees

• Annual membership fee: $______
• Payment schedule: [ ] Annual [ ] Semi-annual [ ] Quarterly
• Payment method: _________________________

2.3 Insurance and Billing

• Membership fees do not include third-party services
• Patient remains responsible for insurance premiums
• Practice will bill insurance for covered services

3. Termination

3.1 Termination Rights

• 30-day written notice required for termination
• Pro-rated refund available for unused services
• Practice reserves right to terminate for cause

4. Signatures

Patient Signature: _________________ Date: _______

Physician Signature: _________________ Date: _______

5. Legal Notices

This agreement does not constitute health insurance. The practice recommends maintaining health insurance coverage.