Patient Concierge Contract
Membership Application and Agreement
Thank you for your interest in joining the true. Women’s Clinic of Grand Rapids, PC. This Membership Application and Agreement describes the terms of your membership in our CONCIERGE program.
*By providing your personal (not shared) email address you consent and acknowledge that we may contact you via unencrypted email and that you acknowledge and agree that we may disclose personal health information (PHI) to you in encrypted email.
By signing below (electronic or otherwise) you agree to the following:
If you have provided us with an email address, buy signing below, you acknowledge and accept the risk of sending or receiving your PHI via unencrypted email, including but not limited to unauthorized access during transit and agree to not hold true. Women’s Clinic of Grand Rapids, PC and true. Women’s Health, LLC or any of its affiliates, employees or agents liable for any damages you may incur as a result of the transmittal of your PHI via unencrypted email and any breach that may occur during transit.
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If you have questions about the contents of this document, you can email the document owner.
Document Name: Patient Concierge Contract
Agree & Sign