ElderConsult — Fees and Services

Patient's Name*

First NameLast Name

Date*

Date

Description	Rate
Capacity Assessment	$995
Geriatric Assessment with Expanded Coverage	$795
Expanded Coverage	$250 per month, billed quarterly
MD Follow Up Visit	$375

Additional Miscllaneous Services
Weekend, Holiday, After Hours* * After hours visits are outside of the standard 9 AM-5 PM Monday-Friday business hours	$250
Urgent Visit Surcharge	$150
Prolonged Visit (rounded to the nearest 30 minutes) **Accrues after initial 30 minute scheduled appointment	$225/each 30 minute block**
Travel Surcharge* *Time spent in excess of 16 miles from office	$150+
Flu Vaccine	$150
PPD Test	$100
Legal Paperwork/Document Review	$450/hour

Payment is due within thirty (30) days from the statement billing date. If payment is not received, you authorize ElderConsult Geriatric Medicine to charge the balance due to the credit card linked to your file. If payment is not received within 60 days, there will be a 5% penalty applied to the outstanding balance every 30 days, until paid in full or other arrangements are made with ElderConsult Geriatric Medicine.

My signature below confirms receipt of the above billing fees, my agreement to pay for all services rendered, in accordance with the terms and conditions set forth in the ElderConsult Services Agreement, and my authorization to charge my credit card (card info will be stored securely) upon my notification by telephone/email and/or in the event payment has not been received when due, as explained above.

Responsible Party's Name*

First NameLast Name

Date*

Date

Responsible Party's Email*

example@example.com

Important Note

Credit card information is required prior to appointment. Please call Jane Ammenti at 650-357-8834 x3.

Responsible Party's Signature — Use your curser to sign in the box below*

Please Verify That You are Human*

v.6-2020 — Fees and Services