1. Insurance and Third-Party Coverage: Optional section for patients who may have private insurance or third-party coverage, describing the relationship between this agreement and such coverage

2. Emergency Services: Section defining protocol and payment obligations for emergency services if applicable to the type of medical care

3. Refund Policy: Details about circumstances under which refunds may be issued, if the facility offers this option

4. Appointment Cancellation Policy: Terms regarding appointment cancellations and associated fees, if applicable

5. Alternative Payment Plans: Description of any available payment plan options or financial assistance programs

6. Quality Assurance: Provisions regarding service standards and quality assurance measures, particularly relevant for ongoing treatment relationships

1. Schedule A - Fee Schedule: Detailed breakdown of fees for different services, procedures, and treatments

2. Schedule B - Payment Plan Details: If applicable, specific terms and conditions of any payment plan arrangements

3. Schedule C - Consent Forms: Required medical consent forms specific to the treatments being provided

4. Appendix 1 - Patient Rights and Responsibilities: Comprehensive list of patient rights and responsibilities under the agreement

5. Appendix 2 - Privacy Policy: Detailed privacy policy and information handling procedures

6. Appendix 3 - Facility Policies: Relevant facility policies that affect service delivery and patient obligations