Diplomate of the American Board of Internal Medicine
Diplomate of the American Board of Integrative Holistic Medicine
PATIENT AGREEMENT
1. I understand that Dr. Levy is treating me as an integrative/holistic medicine specialist, and is not serving as my primary care physician.
2. I understand that Dr. Levy does not use a beeper or an answering service – his cell phone number, 716-479-2240 is provided on the office phone answering machine message. Messages on the cell phone are frequently retrieved, and all phone calls are returned within a reasonable time. However, in the event of an emergency, Patient should either contact his/her Primary Care Physician or go directly to an emergency room.
3. I understand that Patient is responsible for payment for office visits at the time of service, and that Dr. Levy does not participate with any health insurance plans in his office practice. Office visits may be scheduled for 15 minutes ($45), 30 minutes ($90), 45 minutes ($135), or 60 minutes ($180). Upon request, Dr. Levy will provide an encounter form for Patient to submit to his/her health insurance company.
4. I understand that Dr. Levy charges at a rate of $180/hour for phone calls, email exchanges (email correspondence requires a signature on an email consent form), prescription refills, and completion of forms. Payment for these services is due within 30 days of receipt of a bill.
5. I understand that the hourly rate for services may change – Dr. Levy will provide advance notice of any changes in rate.
6. I understand that there is a charge for office appointments which are not cancelled with at least 24 hours notice. The charge for missed visits is $60.
7. I understand that checks returned for insufficient funds will result in an additional charge to the Patient of $30.
___________________________________ ___________________________________
Patient’s Name (Print) Patient’s Primary Care Physician
___________________________________ ____MasterCard________Visa__________
Patient’s Date of Birth Patient’s Credit Card Type (please circle)
____________________/_______________ ___________________________________
Patient’s Phone Number Cell Phone Patient’s Credit Card # and Expiration Date
___________________________________ ___________________________________
Patient’s E-mail Address Patient’s
Health Insurance
(for
informational purposes only)
______________________________________________________________________________
Patient’s Mailing Address (for correspondence purposes)
_______________________________________________________
Patient’s Signature
Date Signed
[Last updated 6/25/08] [Return
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