Patient Acknowledgement and Consent

Patient Acknowledgment and Consent

To be completed by the patient prior to receiving any medical services from Dr. Elder (“the Provider”).

Patient Information:

Name:

Dateof Birth:

Contact Information:

Date:

Consultation and Payment Agreement

I, the undersigned patient, hereby acknowledge and agree to the following terms regarding the medical services provided by Dr. Elder:

  1. Consultation Basis: All consultations with Dr. Elder are based on a cash payment model. Payment is due in full at the time of the visit.
  1. Insurance Claims: Dr. Elder does not participate in any insurance plans. This includes the billing of insurance claims. I understand that I am responsible for the full payment of any and all medical services rendered by Dr. Elder.
  1. Federal Payers and Healthcare Plans under Office of Personal Management: Dr. Elder is expressly prohibited from directly or indirectly causing any claim of any kind to be presented to any federal payers or any health plan under the U.S. Office of Personal Management (OPM), including but not limited to Medicare, Medicaid, Tricare, and Federal Employee Health Benefits Program (FEHBP). As a patient, I understand and agree that any prescriptions, diagnostic studies, or other medical services provided by Dr. Elder cannot and will not be submitted for reimbursement or coverage by any federal payer or healthcare plan under the U.S. Office of Personal Management under Dr. Elder’s medical credentials.
  1. Patient Responsibility: I fully understand and agree that it is my responsibility to ensure that no claims are submitted to any federal payer for reimbursement of any services, prescriptions, or diagnostic studies provided by Dr. Elder.
  1. Acknowledgment of Financial Responsibility: I agree that I am financially responsible for any services provided by Dr. Elder and that I will not seek reimbursement from any federal payer for such services.

Consent to Medical Treatment

By signing below, I voluntarily consent to receive medical care and treatment as deemed necessary by Dr. Elder. I have read, understand, and agree to the terms and conditions outlined in this Medical Services Consent Form. I acknowledge that I have had the opportunity to ask questions about my care and the financial terms of this consent form and that all my questions have been answered to my satisfaction.

Patient Signature:

Date: 

Provider Signature: (Dr. Elder) Date: 

Please ensure that this form is completed and signed before receiving any medical services. This consent form is intended to protect both the patient and the provider by clearly outlining the financial and medical treatment agreement.

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