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This document outlines the terms of membership in the Goodwin Medical Center Concierge Medicine Program, detailing service amenities, annual fees, payment responsibilities, and communication policies

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How to fill out concierge medicine program agreement

01

Read the entire agreement carefully to understand its terms.

02

Fill in your personal information, including your name, address, and contact details.

03

Provide necessary medical history information as requested, ensuring accuracy.

04

Review the fees associated with the concierge medicine program and note any payment schedules.

05

Sign and date the agreement to indicate your acceptance of the terms.

06

Make a copy of the signed agreement for your records.

Who needs concierge medicine program agreement?

01

Individuals seeking personalized and accessible healthcare services.

02

Patients who desire a closer relationship with their healthcare provider.

03

People who want extended appointment times and reduced waiting periods.

04

Those with chronic conditions requiring regular monitoring and care.

05

Individuals who prioritize preventive care and wellness.

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What is concierge medicine program agreement?

A concierge medicine program agreement is a contract between a medical practice and patients that outlines the terms of a membership-based model of healthcare where patients pay an annual fee for enhanced access to their physician and additional services.

Who is required to file concierge medicine program agreement?

Healthcare providers or medical practices that wish to implement a concierge medicine model and charge patients a membership fee are required to file the concierge medicine program agreement.

How to fill out concierge medicine program agreement?

To fill out a concierge medicine program agreement, both the provider and the patient must provide their personal information, agree on the terms of service, specify fees, and outline the services included in the membership. It is advisable to consult legal counsel to ensure compliance with healthcare regulations.

What is the purpose of concierge medicine program agreement?

The purpose of the concierge medicine program agreement is to establish a clear understanding between the physician and the patient regarding services provided, fees, and responsibilities in a concierge healthcare model, ensuring that both parties are on the same page.

What information must be reported on concierge medicine program agreement?

The concierge medicine program agreement must report information such as the patient’s name and contact details, the physician’s name, description of the services provided, the annual fee structure, payment terms, and any other specific terms or conditions related to the concierge service.

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