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PATIENT APPLICATION AND AGREEMENT FORM
Patient(s) identified
below would like to participate in the
mdPersonal
TM
membership offered by Dr. Neil F. Neimark. Patient(s) and
Dr. Neimark acknowledge and agree to the following terms
and conditions in connection with participation in the
Practice.
PRACTICE COMMITMENTS
Dr. Neimark agrees that
the Practice will maintain only a limited number of
patients in order to assure that Patient(s) will have
timely and convenient access to Dr. Neimark, who will be
accessible 24/7 as events and circumstances allow.
EXCLUSIVE MEDICAL PRACTICE
SERVICES FOR MEMBER PATIENTS
24 hours a day, 7 days a
week direct telephone and email access to Dr. Neimark.
Same day or next day appointments with no waiting or
minimal waiting times as circumstances allow.
On time and unhurried appointments for as long as
necessary to cover your presenting medical problems.
Annual Comprehensive Wellness Examination at no
additional cost to Patient(s) for in-house services.
House calls for you and your family when you are too
ill or unable to make it to the office.
In-office lab specimen collection by office staff so
Patient does not have to visit and wait at a laboratory.
Medical concierge service to coordinate Patients
complete healthcare needs, including prescription
refills, scheduling of appointments for specialty care,
laboratory and x-ray needs.
Detailed coordination of specialty care, testing and
accompaniment to specialists when appropriate.
A focus on wellness through the promotion of
preventive medicine and the early detection of disease.
PATIENT COMMITMENTS
To participate in the
Practice, Patient(s) will be required to pay an Annual
Fee according to the following Fee Schedule:
Single Individual: $1800
Couples Package: $3400
Family of 3 Package (2 adults, 1 child): $3600
Family of 4 Package (2 adults, 2 children): $3800
Single Parent Package (1 adult, 1 child): $1800
Each additional child: $360
The Annual Fee is for a
12 month period (Term)
The Annual Fee is due on the effective date of this
Agreement and on or before each anniversary thereafter
as a condition for continuing as a Patient of the
Practice.
The Annual Fee is for services, including the Annual
Comprehensive Wellness Examination, that are not
considered covered benefits by insurance plans or
Medicare. If any of the listed services are considered
covered benefits, then the Annual Fee is for the
remaining list of services.
Financial discounts may be given for certain
individuals based on financial need and/or individual
considerations.
PATIENT ACKNOWLEDGMENTS
Patient acknowledges that
the Practice is a unique program with certain specific
limitations, as follows:
The Annual Comprehensive
Wellness Examination is limited to those services and
procedures performed by Dr. Neimark in his medical
office as part of a comprehensive annual physical
examination. The Annual Comprehensive Wellness
Examination includes collection and review of medical
history, physical examination, stool examination for
blood, EKG, spirometry, urinalysis, blood collection for
the laboratory and a follow-up discussion of the results
along with a plan to improve health. The Annual
Comprehensive Wellness Examination will be performed by
Dr. Neimark without any additional out-of-pocket
expenses by Patient(s) for the services that Dr. Neimark
can perform in his office. Services that are not covered
by the Annual Fee include testing at outside facilities
such as blood tests, x-rays, mammograms, colonoscopy,
heart stress tests, etc.
The patient has financial responsibility to pay for
services that are provided at regular office visits that
are not part of the Annual Comprehensive Wellness
Examination. The Practice will bill Patients insurance
for services, but the financial responsibility for full
payment is that of the Patient(s).
In the even that Dr. Neimark is unavailable, call
coverage will be provided by another physician selected
and overseen by Dr. Neimark.
This Agreement shall automatically expire at the end
of the existing Term unless Patient renews the Agreement
and pays the Annual Fee for the next Term. Upon
expiration or termination of this Agreement, Practice
will transfer Patient(s) medical records and continuing
care to any physician requested by Patient by written
notice.
PATIENT ACCEPTANCE (Please
include date of birth and social security number for
each member)
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Name: |
D.O.B.
SS#: |
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Street: |
Second Adult's Name:
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City: |
Child 1: |
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State: Zip: |
Child 2: |
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Phone: |
Child 3: |
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E-mail: |
Child 4: |
Signature:
_________________________________________
Date:
________________
Total Annual Fee:
__________ (Please refer to the membership categories on
page 1 of this form)
Method of Payment: ( )
Visa ( ) MasterCard ( )American Express ( ) Check: Check
Number: __________
Credit Card Account
Number: ______________________
Expiration Month:_______
Expiration Year ________
PAYMENT: 50% of the Annual
Membership Fee is due upon signature. You may pay off
the remainder by selecting one of the options below:
( ) Semi-Annually (Includes one additional payment 6
months from now. $15 service fee applies)
( ) Quarterly (Includes three additional payments in 3,
6 and 9 months from now. $15 service fee each payment)
( ) Monthly (Includes six additional payments in
1,2,3,4,5 and 6 months from now. $15 service fee each
payment)
( ) I would like to pay my entire fee in one simple
payment.
NOTICE OF ACCEPTANCE:
Dr. Neimark acknowledges
receipt of this agreement and application to become
Patient(s) of Dr. Neimarks Concierge Medical Practice.
This agreement is effective from
_______________________to _____________________
________________________________________
Neil F. Neimark, M.D.
Mail completed to: Neil F.
Neimark, M.D. 4980 Barranca Pkwy Ste 207, Irvine, CA
92604
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