Patient Contract 20-30 Years Old
Wellness Contract for Medical Services
Patient Contract 20-30 Years Old
This contract is between ProntoCare , hereafter referred to as “ProntoCare” and _____________________________, hereafter referred to as “patient.” This contract establishes an agreement for ProntoCare to provide certain medical services to the patient. The terms of this agreement are detailed below:
Covered Medical Services
ProntoCare agrees to provide “Covered Medical Services” to the patient. Covered Medical Services are designed to promote the wellness of the patient through a program of periodic examinations, preventative care, and medical information. Covered Medical Services are detailed in Exhibit A and include the following.
- A total of 5 visits a year including an annual physical and EKG (pay discounted price for any additional visits)
- One virtual visit (on-line visit) per year (optional)
- Free annual wellness lab work
- Wellness, education, and coaching
- No denial for coverage under the plan for pre-existing conditions.
- No copayments apply to the costs for services
- No pre-authorization is required
- No referrals are necessary
- The plan has open enrollment at any time during the year
- Referrals to specialists will be made as appropriate and as indicated
- Services will be provided during regular business hours of ProntoCare
Medical Services EXCLUDE:
Charges for any test, procedures, services or vaccinations not listed in Exhibit A are the responsibility of the patient. Professional services that are not covered by this contract may be provided to the patient by ProntoCare through appropriate separate financial arrangements.
This contract does not cover or include hospital admission(s) or treatment(s). This contract also does not cover urgent services or emergency services requiring hospitalization, or services of other physicians or health care providers arising out of the referral of a medical issue to a specialist or other health care provider.
Costs for Services:
The costs for services provided under this contract is an annual fee of $600.00 which may be paid in full, in advance, and the patient will get an automatic 10% discount, which will adjust the fee to $540.00. The fee may be paid in advance in monthly installments of $50.00 per month. Monthly fees shall be paid in advance by the 1st day of each month. The annual fee or the monthly fee is the base charge for the providing of Covered Medical Services by ProntoCare and must be paid annually or monthly, as applicable, in order for the patient to be eligible to receive the Covered Medical Services under this contract from ProntoCare.
This contract shall be in effect for one year from the date of its execution. Full payment of the annual fee for services or payment of the monthly fee during the term of the contract guarantees this contract for one (1) year from the date of execution of the contract.
The failure to pay the annual fee or the failure to pay the monthly fee, when due, will terminate this contract without notice or demand. This contract is renewable annually with the mutual consent of ProntoCare and the patient. ProntoCare reserves the right to change the annual fee or the monthly installment for service upon renewal. The patient may cancel this contract at any time during the year by giving thirty (30) days written notice to ProntoCare. In the event of cancellation, the patient’s fee is non–refundable.
The patient has read this contract and agrees to the terms specified within:
Patient Name __________________________________________ Date _______________
ProntoCare ____________________________________________ Date _______________
Toll Free: 1 (877) 373- 5346
2204 Ashley Oaks Circle, Suite 102
Wesley Chapel, FL. 33544
Phone: (352) 592-4938
Fax: (352) 592-4941