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New Patient Agreement


        
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PATIENT AGREEMENT

This Patient agreement (the "Agreement") specifies the terms and conditions under which you, the undersigned patient ("Patient"), may participate in the Program ("Program") offered by Bruce Aronwald, D.O. and/or Anthony J. Cioce, D.O. ("your physician").   This Agreement will become effective as the date set forth at the end of this Agreement (the "Effective Date").

1.   Program.   The Program's annual fee encompasses the following services ("Services"):

  • Annual Preventive Care Physical Examination
  • Comprehensive Wellness Plan

In addition to the Services encompassed by the annual fee, the following benefits are provided at no charge:

  • Same or Next Day Appointments
  • Unhurried Visits
  • No Waiting, On time Appointments
  • Physician Availability (24x7)
  • Dedicated Support Personnel
  • E-mail/Fax Access
  • Prescription Facilitation
  • Enhanced Coordination of Necessary Referrals
  • Travel Medical Services
  • Private Reception Area

    2.   Annual Patient Fee.   Each Patient 21 or older will pay an annual fee of $1800 ("Annual Fee").   Each Patient under the age of 21 will pay an annual fee of $900.

    3.   Renewals and Termination.   The Annual Fee covers a period of one (1) year.   Failure to pay the renewal Annual Fee prior to the anniversary of the Effective Date shall result in termination of your participation in the Program.    (For example, if the Effective Date is May 15th, 2003 then you must renew on or before May 14th, 2004).   You or your physician may terminate this Agreement at any time upon 30-days prior written notice.   If you or your physician terminate this Agreement for any reason, you will be entitled to a prorated refund of any unused portion of the Annual Fee.   Such prorated refund will be based on the number of days you have participated in the Program, and whether you received your Annual Preventive Care Physical Examination.   Upon your physician.s receipt of this Agreement and the Annual Fee, your physician shall have the option, in his sole and absolute discretion, not to accept this Agreement and to return your payment to you (e.g., due to limitations on the number of patients).

    4.   Medical Care Services Excluded from Annual Fee.   The Annual Fee specified herein covers only the defined "Services".   Except for your Annual Preventive Care Physical Examinations and Comprehensive Wellness Plan, you and/or your insurer, as the case may be, will be financially responsible for paying for all healthcare and medical care services received by you from your physician and his staff.    Your physician will be you and/or your insurer, as the case may be, for those medical or health care services provided to you.

    5.  Co-Payments.   The Annual Fee does not affect the co-payments, co-insurance, or deductibles that you are required to pay pursuant to the terms of your insurance coverage.   You will be financially responsible for any co-payments, co-insurance of deductible amounts required by your insurer.

    6.   E-mail Communication; Privacy.   If you wish to send e-mail communications to and receive e-mail responses from your physician and/or his employees, agents, and representatives, you should be aware that e-mail is not a secure medium for sending or receiving potentially sensitive personal health information.    Although your physician will take steps to keep your communications confidential and secure, the confidentiality of e-mail communications cannot be assured or guaranteed.   You also acknowledge and understand that e-mail is not a good medium for urgent or time-sensitive, you must communicate with your physician by telephone or in person.   You acknowledge and understand that, at the discretion or your physician, your e-mail may become part of your permanent medical record.

    7.   Entire Agreement.   Each of the undersigned agrees to the terms of this Agreement, all of which are expressed herein.   There are no promises of representations except as set forth herein.

    8.   Notices.   Any communication required or permitted to be sent under this Agreement shall be in writing and sent via facsimile or via certified mail, return receipt requested, to the addresses set forth below.   Any change in address shall be communicated in accordance with the provisions of this section.

    9.   Governing Law.   This Agreement shall be governed by and construed in accordance with the laws of the State of New Jersey.
________________________________________________________________________________
(Print Name) (Member's Signature) (Date)
_____________________________________________________
Date of Birth Social Security Number
________________________________________________________________________________
Street Address
________________________________________________________________________________
City State Zip
________________________________________________________________________________
Phone (H) (W) (Cell)

_______________________________________________________________
Email

        
Physician Signature________________________________    Date___________________________

BILLING
You may pay your Annual Fee with either a check or your Credit Card.   Please make your checks payable to Premier Medical Care.

  • Individual Annual Fee $1,800
  • Couple Annual Fee $3,600
  • Child Annual Fee (under 21) $900
      
    

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All Rights Reserved.