Primary Care Treatment Agreement and Informed Consent

This agreement is entered into on [DATE] between:

Provider: [PHYSICIAN NAME], MD Practice: [PRACTICE NAME] Patient: [PATIENT NAME] DOB: [DATE OF BIRTH]

1. SCOPE OF SERVICES

I understand and agree that my healthcare provider will:

• Provide comprehensive primary care services
• Order appropriate diagnostic tests
• Prescribe medications as medically necessary
• Make referrals to specialists when indicated
• Maintain accurate and complete medical records

2. PATIENT RESPONSIBILITIES

I agree to:

• Provide accurate and complete medical history
• Inform the provider of all current medications
• Keep scheduled appointments or provide 24-hour notice of cancellation
• Follow agreed-upon treatment plans
• Update contact and insurance information promptly

3. COMMUNICATION

• Office phone hours: [HOURS]
• After-hours emergencies: Call [EMERGENCY NUMBER]
• Patient portal messages will be answered within [TIME FRAME]

4. PRESCRIPTION POLICIES

• Medication refills require 48-hour notice
• Controlled substances require in-person visits every [TIME PERIOD]
• Lost prescriptions will not be replaced without documentation

5. FINANCIAL RESPONSIBILITIES

• I understand I am responsible for all charges not covered by insurance
• Copayments are due at time of service
• Outstanding balances must be addressed before non-urgent visits

6. TERMINATION

Either party may terminate this agreement with written notice, ensuring 30 days of emergency care coverage during transition.

SIGNATURES

Patient Signature: _______________ Date: _______________

Provider Signature: ______________ Date: _______________

[PRACTICE LETTERHEAD] [CONTACT INFORMATION]