PATIENT SERVICE AGREEMENT

This Patient Service Agreement (“Agreement”) is made between Signature Care Services (“Signature Care,” “Provider,” “We,” or “Us”) and the undersigned client (“Client,” “Patient,” or “You”) for private-pay concierge nursing and nurse practitioner (NP) services.

This Agreement outlines the scope of services, limitations, responsibilities, financial terms, and legal protections for both the Client and Provider. By signing below, the Client agrees to all terms within this Agreement.

1. NATURE OF SERVICES

Signature Care Services provides private-pay, nonemergency, in-home nursing and nurse practitioner services, including but not limited to:

• Nursing assessments
• Vitals monitoring
  
• Medication set-up and reminders
  
• Wound care and skilled nursing
  
• Chronic condition support
  
• Lab draws (in-home or coordinating with outside laboratory)
  
• Care coordination
  
• NP evaluation and treatment within approved scope
  
• Limited urgent care services (described below)

Signature Care practices under Michigan state law with NP services provided under a collaborative agreement with a licensed physician.

2. URGENT CARE SERVICES PROVIDED THROUGH INKSTER URGENT CARE

Signature Care offers coordination for urgent medical evaluation when appropriate; however:

Urgent Care services are provided exclusively through:

Inkster Urgent Care
388 Inkster Rd.
Inkster, MI 48141

Inkster Urgent Care is a separate and independent medical entity, with its own providers, billing policies, and legal responsibilities.

Inkster Urgent Care requires separate intake forms. While we recommend completing them beforehand, you can also fill them out during your visit.

IMPORTANT DISCLAIMERS:

1. Inkster Urgent Care is not owned by, affiliated with, or operated by Signature Care.
   
2. Any urgent care visit (virtual or in-person) is billed separately by Inkster Urgent Care.
   
3. Any insurance coverage, co-pays, deductibles, or denials are governed solely by Inkster Urgent Care and the Patient’s insurance.
   
4. Signature Care does not guarantee appointment availability, insurance approval, medical outcomes, or clinical decisions made by Inkster Urgent Care.
   
5. Signature Care acts solely to coordinate or initiate referral for urgent care needs when clinically
   appropriate.

Signature Care accepts no responsibility for decisions, treatment, billing, or clinical outcomes provided by Inkster Urgent Care or any other outside provider.

3. SIGNATURE CARE IS NOT A PRIMARY CARE PROVIDER

Signature Care Services does NOT function as a Primary Care Provider (PCP).

We do not replace your PCP or specialist.

You must maintain an active relationship with your regular primary care provider for:

• Annual physicals
  
• Preventive screenings (Pap smear, mammogram, prostate exam, colonoscopy, etc.)
• Chronic disease management
  
• Long-term medication management or controlled substance prescriptions
  
• Immunizations
  
• Diagnostic testing requiring physician oversight
  
• Specialist referrals outside NP scope
  

Failure to maintain appropriate medical care outside of Signature Care may result in discharge from our services.

4. LIMITATIONS OF SERVICE & EMERGENCY DISCLAIMER

Signature Care does not provide emergency medical care.

The following symptoms require calling 911 immediately:

• Chest pain or pressure
  
• Difficulty breathing or severe shortness of breath
  
• Stroke symptoms (slurred speech, facial droop, weakness)
  
• Severe bleeding
  
• Loss of consciousness
  
• Seizure
  
• Severe allergic reaction / anaphylaxis
  
• Trauma or suspected fractures
  
• Suicidal ideation or psychiatric crisis
  

Signature Care will not be held liable for any delay in emergency evaluation if the Patient fails to call 911 or delays seeking proper medical treatment.

5. DETAILED LIABILITY & HOLD HARMLESS CLAUSE

The Patient acknowledges and agrees to the following:

1. Signature Care provides non-emergency, private-pay, inhome nursing and NP services.
   
2. No outcome, cure, improvement, or result is guaranteed.
   
3. The Patient is responsible for providing truthful and complete medical information.
   
4. Signature Care is not responsible for:
   
   • Worsening of conditions due to lack of disclosure
     
   • Failure to seek emergency care
     
   • Complications from refusing recommended treatment
     
   • Delays caused by outside providers (pharmacies, labs, urgent care, etc.)
     
   • Equipment failure in the home
5. The Patient agrees to hold harmless, indemnify, and release Signature Care, its owners, employees,
   contractors, nurses, nurse practitioners, collaborating physicians, and representatives from any and all claims, liabilities, damages, or losses arising from:
   
   • Services provided
   • Services declined
     
   • Referrals made
     
   • Care provided by outside entities (including Inkster Urgent Care)
     
   • Any adverse medical events not caused by gross negligence or willful misconduct
     
6. In no case shall Signature Care be liable for indirect, incidental, special, or consequential damages. This clause is intended to be as broad as Michigan law allows.

6. PAYMENT TERMS

• All services are private-pay only.
  
• Payment must be made in full prior to each visit.
  
• Same-day visits, after-hours service, and travel fees may apply.
  
• Missed or canceled visits with fewer than 24 hours’ notice may be charged a cancellation fee.
  
• NP services, forms, letters, orders, and care plans are billed separately.
  
• Inkster Urgent Care billing is completely separate and not controlled by Signature Care.
  

7. INITIAL INTAKE / NEW PATIENT APPPOINTMENT FEE

The patient understand that all new patients are required to complete an initial intake / new patient appointment prior to receiving ongoing services.

• The initial intake visit fee is $100, due at the time of scheduling or before the visit begins.
• This visit includes a review of patient's medical history, medications, vital signs, home and safety assessment, and development of a preliminary care plan.
• The patient understand that this fee covers the intake visit only and service needed. This fee does not include any additional services, procedures, or follow-up visits
• Patient understand that if they cancel or reschedule their intake visit with less than 24 hours’ notice, or if they do not show for my scheduled appointment, the $100 fee may be non-refundable at the practice’s discretion.
• Patient acknowledge that completion of the intake visit does not guarantee acceptance for ongoing services if their needs fall outside the scope or capacity of the practice.

8. HIPAA & PRIVACY

Signature Care complies with all HIPAA laws.

We may share relevant information with:

• Your PCP
• Specialists
  
• Pharmacies
  
• Inkster Urgent Care
  
• Emergency services
  
• Authorized family contacts
  

No other information will be released without your written consent except where required by law.

9. TERMINATION OF SERVICES

Signature Care may terminate services immediately for:

• Nonpayment
  
• Unsafe environment
  
• Abusive or threatening behavior
• Repeated cancellations
  
• Medical needs beyond our scope
  
• Inappropriate requests outside Michigan NP/nursing scope of practice
  
• Failure to comply with care recommendations
  

10. ACKNOWLEDGEMENT & CONSENT

By signing below, the Patient acknowledges:

• They understand Signature Care is not a primary care provider.
• They understand urgent care services are through Inkster Urgent Care, a separate entity.
  
• They understand limitations of services and emergency exclusions.
  
• They understand and accept the liability, indemnity, and hold harmless terms.
  
• They consent to in-home nursing and NP services provided by Signature Care.