Get Patient Physician Agreement Form

Patient outcomes depend on successful communication. The physician who encourages open communication may obtain more complete information, enhance the prospect of a more accurate diagnosis, and facilitate appropriate counseling, thus potentially improving adherence to treatment plans that benefits long-term health.

I accept responsibility for all charges if I do not have medical insurance. I have been informed that the services provided may not be covered by my insurance plan. I elect to proceed with service with the understanding that I may be personally responsible to pay for the service being rendered to me.

A physician-patient relationship exists because of a contract, express or implied, that the doctor will treat the patient with proper professional skill. A physician need not have physical contact or deal directly with a patient to create the relationship.

Placing trust in a doctor helps them maintain or regain their health and well-being. This unique relationship encompasses 4 key elements: mutual knowledge, trust, loyalty, and regard. Knowledge refers to the doctor's knowledge of the patient as well as the patient's knowledge of the doctor.

Responsibilities of physicians & patients The relationship between a patient and a physician is based on trust, which gives rise to physicians' ethical responsibility to place patients' welfare above the physician's own self-interest.

Generally, the relationship is entered into by mutual consent between physician and patient (or surrogate). However, in certain circumstances a limited patient-physician relationship may be created without the patient's (or surrogate's) explicit agreement.

(Exceptions are made when emergency care is needed and when refusal to treat is based on discrimination). However, a patient-physician relationship is generally formed when a physician affirmatively acts in a patient's case by examining, diagnosing, treating, or agreeing to do so [5].

These documents contain statements to help ensure patients understand their role and responsibilities regarding their treatment (e.g., how to obtain refills, conditions of medication use), the conditions under which their treatment may be terminated, and the responsibilities of the health care provider.