Medical Services Agreement Medical Services Agreement
(Telehealth or Brick-and-Mortar)
Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., C.O., Primary Medical of IN, P.C.
Name: {{patient_first_name}} {{patient_last_name}}
Date of Birth: {{patient_birthdate}}
Agreement Date:
Term:
Patient agrees that medical service is ongoing and continuous until patient notifies company in writing with 60 days' notice prior to next scheduled payment date. Service charges will occur monthly on the Agreement date. For patients who have previously prepaid for medical services, the patient card-on-file will be charged the monthly amount per the SERVICES CHARGE SHEET. If savings are available via a pre-paid option, then patient may be eligible to elect this option in the future.
Medical Service Fees:
Patient agrees to pay the amount per the SERVICES CHARGE SHEET for services purchased. For patients who have elected not to pre-pay, services fees are subject to change with 15-day notice.
Cancellation:
Patient understands that due to medical services and active prescriptions being provided, a cancellation fee equal to two months of medical service fees will be charged upon notice of intent to cancel. Additionally, within 10 business days of cancellation notice, Patient agrees to sign the cancellation agreement AND schedule a meeting with a provider to determine termination dates of prescriptive care and transition, if any, of files.
Card Authorization:
Patient agrees to keep the CREDIT CARD AUTHORIZATION ON FILE AGREEMENT current at all times, including card expiration and account number.
Form Complete
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