Aloha Nui Family Practice, LLC
Physician / Client Service Agreement

*Please also print and complete New Client & Medical Records forms.

1.      I agree to be kind, courteous and respectful at all times to the staff at Aloha Nui Family Practice, LLC .

2.      I agree to receive kind, courteous and respectful treatment at all times by the staff at Aloha Nui Family Practice, LLC.

3.      I agree to keep my scheduled appointments and to notify Aloha Nui Family Practice, LLC within 24 hours that I will be unable to keep my scheduled appointment and that I will need to reschedule. I understand that a $25 fee will be charged if I fail to notify Aloha Nui Family Practice, LLC and that the fee is due at time of my next scheduled appointment.

4.      I agree to have Aloha Nui Family Practice, LLC contact me if my appointment has been cancelled or changed.

5.      I agree that if I am greater than 15 minutes late for my appointment that I must reschedule.

6.      I agree to pay all applicable copays at time of service.

7.      I agree to pay all applicable fees for the medical services that I receive from Aloha Nui Family Practice, LLC that are not reimbursed by my insurance company.

8.      I agree to contact Aloha Nui Family Practice, LLC immediately if there is any change in my health.

9.      I agree to have Aloha Nui Family Practice, LLC contact me if there is any change in my health.

10.  I agree to contact Aloha Nui Family Practice, LLC immediately if there is any change in my insurance status.

11.  I agree to have Aloha Nui Family Practice, LLC contact me if there is any change in my insurance status.

12.  I understand that Aloha Nui Family Practice, LLC does not routinely treat chronic pain or workman’s comprehensive injuries, and that I will be my responsibility to secure medical treatment with a designated specialist.

13.  I understand under HIPPA regulations that my medical information will be shared with any specialist medical provider to improve the medical care for which I am referred.

14.  I understand that everything will be done to keep my appointment time scheduled but that at times I may have to wait past my appointment time to be seen by my physician.

15.  I understand that this service agreement can be terminated at any time and for any reason by myself or Aloha Nui Family Practice, LLC. This termination of services will be effective immediately. I understand that only emergency care will be offered for 30 days from the termination date. I understand that I will be mailed a letter of termination by Aloha Nui Family Practice, LLC for confirmation of termination of medical services.

16.  I understand that by writing my name and signing below that I have read and agree to all of the above.

Full Name(*please print): ___________________________________________________________________________________________

Signature: ____________________________________           Date: ________ / ________ / 20________