Primary Care Physician Notice Agreement

This Primary Care Physician Notice Agreement (this “Agreement”) is made effective as of ___________________ (current date) between Absolute Medical Solutions, Inc. (AMSI), 911 Bolender Drive, Del Ray Beach, FL  33483 and ____________________________ (name) of _____________________________.

The purpose of this agreement is to ensure that the CLIENT HAS NOTIFIED of WILL NOTIFY THEIR Primary Care Physician (PCP) that they are using the services of AMSI.

Therefore, the parties agree as follows:

1. CLIENT has informed their PCP that they are utilizing the services of AMSI to continue their health management program.
2. CLIENT acknowledges that use of AMSI services does not in any way replace their PCP and will continue to consult with their PCP on a regular basis or as often as deemed necessary by the PCP and maintain up to date medical records as required.
3. CLIENT is not using the services of any other outsourcing service for the purpose of obtaining health management treatments.

This agreement must be signed, notarized and received by AMSI prior to any services being rendered.

Please Print:

Name:__________________________________________

Address:________________________________________

City:___________________   State______   Zip_________

Signature:_________________________________    Date:_________________________
           

I hereby acknowledge that ___________________________(name) signed this document on this _______ day of _____________________, ___________ before me a Notary Public for the State of _______________________.

Notary Signature:______________________________

My Commission Expires: ________________________                (Notary Seal)