Page 1 of 2 - Reflex Sympathetic Dystrophy - RSD Foundation
Page 1 of 2
DATE: _______________
The RSD / CRPS Treatment Center
and Research Institute
This letter confirms an agreement between the party identified below (the “Purchaser”) and the Anthony F. Kirkpatrick, M.D., Ph.D. for the performance of
on ___________________ D.O.B. _____________ based upon the following terms and conditions:
1. Reimbursement and Services.
The Purchaser agrees to pay Dr. Kirkpatirck the following compensation for the above services provided by Dr. Kirkpatrick: the base fixed fee of
$_______________.
2. Conditions.
Payment is required in advance. There is an additional charge of $250 for same-day cancellations or failure to attend the appointment. All cancellations must be made within 48 hours in order to receive full refund of the prepaid amount.
3. Services.
All payments shall be made by check payable to:
The RSD / CRPS Treatment Center and Research Institute
1910 E. Busch Blvd.
Tampa, Florida 33612
(813) 995-5511
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Please have an authorized representative sign this letter and return it to my office.
THE PURCHASER AGREES TO ALL OF THE TERMS AND CONDITIONS OUTLINED IN THIS LETTER FOR _____________________ D.O.B. _________________.
Name of Purchaser:
____________________________ _______________________
(Signature of Authorized Agent) (Date)
____________________________ _______________________(Printed Name) (Title)
____________________________
(Telephone Number)
Fee schedule and CPT Codes are published:
File/ My Documents/Fee Agreement
2/10/08
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