Form - Excelle MD

MEDICAL SERVICE CONTRACT

A - PATIENT INFORMATIONS

Full name*

Date of birth

1

Day*

January

January
February
March
April
May
June
July
August
September
October
November
December

Month*

Year*

RAMQ (Health Insurance)*

Expiration date*

Full name of the representative (if under 14 years old)

Address*

Street*

Town*

Postal code*

Main phone number*

Secondary phone number

Email*

C - TO BE COMPLETED IF THE PATIENT IS BETWEEN 14 AND 18 YEARS OLD

Do you authorize the representative named in the Patient Information section above to receive the results on your behalf? NoYes I authorize the representative to receive my results.

Yes

D - TO BE COMPLETED IF LANGUAGE IS A BARRIER BETWEEN THE PATIENT AND EXCELLEMD

The person mentioned below will serve as a translator and is also authorized to obtain results on my behalf.

Full name

E - OTHER INFORMATIONS

Name of your pharmacy

Address of your pharmacy

Phone number

Fax

TERMS AND CONDITIONS OF THE MEDICAL SERVICE CONTRACT

1. PURPOSE OF THE CONTRACT

In accordance with this Contract, ExcelleMD is a provider of private medical services. The Patient accepts the private medical care services offered by ExcelleMD in accordance with the terms and conditions of this Contract.

2. LEGAL DISCLOSURE

ExcelleMD regroups non-participating physicians and to this effect, the health care providers do not participate in the Québec Health Insurance Plan as governed by the Health Insurance Act. The Patient acknowledges that he/she cannot claim the reimbursement of any consultation fees nor any other charges to the Régie de l’assurance maladie du Québec (RAMQ). As such, the Patient must pay the health care received from ExcelleMD and he/she is ineligible for a RAMQ refund.

3. PATIENT OBLIGATION

The Patient must call ExcelleMD to make an appointment to see a doctor. The Patient agrees to pay all fees in accordance with the ExcelleMD fee rate in effect. In addition, the Patient agrees to pay, as applicable, additional consult costs, including without limitation, the surgical instruments, medication, medical equipment and/or nursing services.

4. FEES

The complete list of applicable fees is posted at the clinic and is subject to change without notice. The Patient accepts to pay the cancellation or no-show fees in accordance with the ExcelleMD policy in effect. The service fees are charge to the Patient. Please note the following fees:

Cancelled appointment without 24-hour notice or no-show: $45.00
No-show or cancelled annual exam appointment without 24-hour notice: $90.00
An administrative fee of 20$ will be charged annually.
NB: Clauses not applicable for company consultations.

Prices are subject to change without notice.

5. DECLARATION

Prior to the execution of this Contract, the Patient declares having received the explanations required to make a decision to retain the private medical services of ExcelleMD.

Date*

CONSENT TO ACCESS TO PERSONAL INFORMATION AND TRANSMISSION

I give the doctors of clinic ExcelleMD permission to access the information necessary to the delivery of care or social services required by my health. I also authorize ExcelleMD to submit this information in the strictest confidence, to any related professional in the health and social services. In addition, I agree that the information generated by my visits can be forwarded to the family doctor and doctors and professionals of family medicine groups where I receive services upon my request. This consent ceases to have effect upon ExcelleMD receipt of a written notice.