TERMS & CONDITIONS

Disclaimer: This is a general example for informational purposes only and is not legal advice. A licensed healthcare attorney in your state should review any patient agreement before use.

Terms and Conditions of Care
Welcome to dream primary care. By receiving services from our office, you agree to the following Terms and Conditions.
1. Scope of Services
Our practice provides primary healthcare services including preventive care, diagnosis, treatment, chronic disease management, wellness visits, and other medically appropriate services determined by the provider.
Emergency services are not provided. If you are experiencing a medical emergency, call 911 or go to the nearest emergency room immediately.

2. Patient Responsibilities
Patients agree to:
   •    Provide accurate and complete medical and insurance information
   •    Inform the office of changes in address, phone number, or insurance coverage
   •    Follow treatment plans and medical advice
   •    Treat staff and providers respectfully
   •    Attend scheduled appointments or provide proper cancellation notice

3. Appointments and Cancellations
Patients are encouraged to arrive on time for appointments.
   •    Appointments canceled with less than 24 hours’ notice may be subject to a cancellation fee.
   •    Patients arriving late may need to reschedule.
   •    Repeated missed appointments may result in dismissal from the practice.

4. Financial Policy
Payment is due at the time services are rendered unless prior arrangements have been made.
Patients are responsible for:
   •    Co-pays
   •    Deductibles
   •    Coinsurance amounts
   •    Non-covered services
Outstanding balances may be referred to collections if unpaid after reasonable notice.
Returned checks may incur additional fees.

5. Insurance Billing
As a courtesy, we may bill insurance companies on your behalf. However:
   •    Insurance coverage is the patient’s responsibility.
   •    Patients remain financially responsible for all charges not paid by insurance.
   •    Coverage verification does not guarantee payment.

6. Prescription Refills
Prescription refill requests should be submitted during normal business hours.
Please allow:
   •    48–72 business hours for routine refills
   •    Additional time for controlled substances or prior authorizations
Refills may require an office visit at the provider’s discretion.

7. Communication and Electronic Messaging
By providing contact information, patients consent to communications by:
   •    Phone
   •    Voicemail
   •    Email
   •    Text message
   •    Patient portal
Electronic communications may not always be secure. Patients should avoid sending urgent or emergency medical information electronically.

8. Privacy Practices
Our office complies with applicable privacy laws, including HIPAA regulations.
Patients have the right to:
   •    Access medical records
   •    Request corrections to records
   •    Receive a copy of our Notice of Privacy Practices

9. Telehealth Services
Telehealth services may be offered when appropriate.
By participating in telehealth visits, patients acknowledge:
   •    Certain risks exist with electronic communications
   •    Technical failures may interrupt services
   •    Telehealth may not be appropriate for all conditions

10. Controlled Substances Policy
Controlled medications may require:
   •    Periodic office visits
   •    Drug screening
   •    Medication agreements
   •    Review of prescription monitoring databases
Lost or stolen prescriptions may not be replaced.

11. Termination of Care
The practice reserves the right to terminate the provider-patient relationship for reasons including:
   •    Nonpayment
   •    Repeated missed appointments
   •    Disruptive or abusive behavior
   •    Failure to comply with treatment recommendations
Patients will receive written notice consistent with applicable laws.

12. Consent for Treatment
By signing below, the patient voluntarily consents to medical evaluation, diagnostic testing, and treatment deemed appropriate by the provider.

Acknowledgment
I acknowledge that I have read and understand these Terms and Conditions and agree to comply with office policies.
Patient Name: _______________________
Signature: ___________________________
Date: _______________________________

If you'd like, I can also provide:
   •    A shorter one-page version
   •    A more formal legal version
   •    A Direct Primary Care (DPC) membership agreement
   •    Pediatric primary care terms
   •    Concierge medicine terms
   •    HIPAA/privacy notice language
   •    Florida-specific wording for your office in Jacksonville