This Professional Services Agreement (Agreement) sets forth the conditions under which ELDERCONSULT, INC., a California professional S-Corporation; (ElderConsult) will provide primary care medical services to the individual named above (You).
1. Primary Care / Expanded Coverage Medical Service
Alternative Care Issues:
2. Consulting Services
3. Capacity Evaluation: Elder Abuse
4. Conduct of Practice
ElderConsult Professionals and Our Providers Will Conduct Their Practice to:
ElderConsult will charge you on a fee-for-service basis for the services it provides to you. ElderConsult will provide a schedule of services and the fees charged for those services upon your request. That schedule is subject to revision from time to time.
By signing below, you agree to all the terms and conditions of this Agreement including agreement to pay for all services rendered and confirm your understanding that ElderConsult does not accept any form of health insurance.
After signing here, review #7 and sign below.
If signed by someone other than the patient, the individual signing below represents and warrants to ElderConsult that he or she has the legal authority to execute this Agreement on the patient’s behalf.
*If yes, please provide a copy of this authorization for our records, if not already submitted.
v.9-2020 — Professional Services Agreement