Fee for Service Medical Agreement
1. Medical Consent: I consent to any medical treatments or procedures which may be performed on an outpatient basis (excluding emergency treatment or services), which may include but are not limited to medications, injections, taking of medical photographs, laboratory procedures, and/or x-ray examinations provided to me under the general and special instructions of the physicians, staff, or other health care providers of LISA R CHACKO MD PLLC assisting in my care.
2. Financial Obligation: I understand that all Fee For Service (FFS) charges are due at the time of service. A deposit is required at the time of booking and the remaining balance will be billed to the card used for deposit payment on the date of service. I agree to pay LISA R CHACKO MD PLLC for all charges for healthcare services and professional services provided to me by physicians and other healthcare professionals. The Fee For Service charges are as follows:
- New Patient Appointment: $350.00
- Follow up Appointment: $250.00
- Three Month Consult: $600.00
- Annual Membership: $2000.00
3. Acceptable forms of payment include Visa, MasterCard, American Express and Debit cards.
4. Non-Participation in Insurance: The Practice does not participate with any health plans, HMO panels, or any other third-party payor. As such, we will not submit bills or seek reimbursement from any third-party payors for the Services provided under this Agreement.
5. Medicare & Medicaid: The Patient understands that the Practice is prohibited from rendering services to recipients of government sponsored health insurance programs including Medicare and Medicaid.
6. Release of Medical Information: I hereby authorize LISA R CHACKO MD PLLC to release any information in my chart to any practitioner, doctor, hospital, or medical institution to which I may be referred to assist in my care. Additionally, I authorize any request for medical information from any medical practitioner, doctor, hospital, or medical institution to assist in the care of the above-named patient.
7. Consent to Treatment Using Telemedicine: I consent to treatment involving the use of electronic communications to enable health care providers at different locations to share my individual patient medical information for diagnosis, therapy, follow-up, and/or education purposes. I consent to forwarding my information to a third party as needed to receive telemedicine services, and I understand that existing confidentiality protections apply. I acknowledge that while telemedicine can be used to provide improved access to medical care, as with any medical procedure, there are potential risks and no results can be guaranteed or assured. These risks include, but are not limited to: technical problems with the information transmission; equipment failures that could result in lost information or delays in treatment. I understand that I have a right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future treatment and without risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
8. The undersigned certifies that he/she has read and agrees to the above and foregoing, and received a copy thereof, and is duly authorized to enter into this fee for service agreement.