Membership Agreement

***This is for information purposes. Information is subject to change. The Membership Agreement will be reviewed in the office at the time of enrollment. ***

Patient Agreement

Membership Plan

Ideal Wellness Family Practice, PC

This is an Agreement entered into on _________________, 20___, between Ideal Wellness Family Practice, PC (Clinic, Practice, Us or We), and ________________________________ (Patient or You).

Background

The CLINIC is a primary care practice, which delivers primary care services through its physician, Dr. Jessica Orner (Physician), at 701 Leon Avenue, Palmyra, PA 17078. In exchange for certain fees, the CLINIC, agrees to provide You with the Services described in this Agreement on the terms and conditions contained in this Agreement.

Definitions

1. Patient. In this Agreement, “Patient” means the persons for whom the Physician shall provide care, and who have signed this agreement or are listed on the document attached as Appendix B, which is a part of this agreement.

2. Services. In this Agreement, “Services”, means the collection of services, offered to you by Us in this Agreement. These Services are listed in Appendix A, which is attached and a part of this Agreement.

Agreement

3. Term. This Agreement will commence on the date signed by the parties below and shall continue for a period of one month.

4. Renewal. The Agreement will automatically renew each month unless either party cancels the Agreement by giving 30 days written cancellation notice.

5. Termination. Regardless of anything written above, You always have the right to cancel this agreement. Either party can end this agreement at any time by giving the other party 30 days written notice.

6. Payments and Refunds – Amount and Methods. In exchange for the Services (see Appendix A(1)), You agree to pay Us a monthly fee in the amount that appears in Appendix C, which is attached and is part of this Agreement.

a) The Parties agree that the required method of monthly payment shall be by automatic payment through a debit or credit card, or bank draft.

b) These fees may change with time. You will be notified at least 30 days in advance of any fee changes.

c) If this Agreement is cancelled by either party before the Agreement ends, We will review and settle your account as follows:

(i) We will refund to You the unused portion of your fees on a per diem basis; or

(ii) If the Value of the Services you received over the term of the Agreement exceeds the amount You paid in membership fees, You shall reimburse the CLINIC in an amount equal to the difference between the value of the services received and the amount You paid in membership fees over the term of the Agreement. The Parties agree that the value of the services is equal to the CLINIC’s usual and customary fee-for-service charges. A copy of these fees is available on request.

7. Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its Physician, participate in any health insurance outside of Original Medicare. Neither make any representations that the fees paid under this Agreement are covered by the Patient’s health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan or HSA and to submit any required billing.

8. Medicare. Your initials on this clause of the Agreement acknowledges Your understanding that neither Physician nor Practice is Opted-Out of Medicare. Therefore, they are legally required to submit claims to Medicare for covered services.

9. This Is Not Health Insurance. Your initials on this clause of the Agreement acknowledges Your understanding that this Agreement is not an insurance plan or a substitute for health insurance. The Patient understands that this Agreement does not replace any existing or future health insurance or health plan coverage that Patient may carry. The Agreement does not include hospital services, or any services not personally provided by the CLINIC, or its employees. The Patient acknowledges that the CLINIC has advised the Patient to obtain or keep in full force, health insurance that will cover the Patient for healthcare not personally delivered by the CLINIC, and for hospitalizations and catastrophic events.

10. Communications. The Patient acknowledges that although Clinic shall comply with HIPAA privacy requirements, communications with the Physician using e-mail, facsimile, video chat, cell phone, texting, and other forms of electronic communication can never be absolutely guaranteed to be secure or confidential methods of communications. As such, Patient expressly waives the Physician’s obligation to guarantee confidentiality with respect to the above means of communication. Patient further acknowledges that all such communications may become a part of the medical record.

By providing an e-mail address and cell phone number on the attached Appendix B, the Patient authorizes the CLINIC, and its Physicians to communicate with him/her by email or text message regarding the Patient’s “protected health information” (PHI). The Patient further acknowledges that:

(a) E-mail and text message are not necessarily secure mediums for sending or receiving PHI, and there is always a possibility that a third party may gain access;

(b) Although the Physician will make all reasonable efforts to keep e-mail and text communications confidential and secure, neither the CLINIC, nor the Physician can assure or guarantee the absolute confidentiality of these communications;

(c) At the discretion of the Physician, e-mail and/or text communications may be made a part of Patient’s permanent medical record; and

(d) You understand and agree that e-mail and text messaging are not an appropriate means of communication in an emergency, for time-sensitive problems, or for disclosing sensitive information. In an emergency, or a situation that You could reasonably expect to develop into an emergency, You understand and agree to call 911 or go to the nearest Emergency room, and follow the directions of emergency personnel.

(e) Email/Text Messaging Usage. If You do not receive a response to an email or text message within 1 business day, You agree that you will contact the Physician by telephone or other means.

(f) Technical Failure. Neither the CLINIC, nor the Physician will be liable for any loss, injury, or expense arising from a delay in responding to Patient, when that delay is caused by technical failure. Examples of technical failures: (i) failures caused by an internet or cell phone service provider; (ii) power outages; (iii) failure of electronic messaging software, or e-mail provider; (iv) failure of the CLINIC’s computers or computer network, or faulty telephone or cable data transmission; (iv) any interception of e-mail communications by a third party which is unauthorized by the CLINIC; or (v) Patient’s failure to comply with the guidelines for use of e-mail or text messaging, as described in this Agreement.

11. Physician Absence. From time to time, due to vacations, illness, or personal emergency, the Physician may be temporarily unavailable to provide the services referred to in this agreement. In order to assist Patients in scheduling non-urgent visits, CLINIC will notify Patients of any planned Physician absences as soon as the dates are confirmed. In the event of the Physician’s unplanned absences, Patient’s calls to the Physician or to the Physician’s office will be directed to a provider who is “covering” for the Physician during his/her absence. Dr. Orner will make every effort to arrange for coverage but cannot guarantee such coverage.

12. Change of Law. If there is a change of any relevant law, regulation or rule, federal, state or local, which affects the terms of this Agreement, the parties agree to amend this Agreement to comply with the law.

13. Severability. If any part of this Agreement is considered legally invalid or unenforceable by a court of competent jurisdiction, that part will be amended to the extent necessary to be enforceable, and the remainder of the contract will stay in force as originally written.

14. Reimbursement for Services Rendered. If this Agreement is held to be invalid for any reason, and the CLINIC is required to refund fees paid by You, You agree to pay the CLINIC an amount equal to the fair market value of the medical services You received during the time period for which the refunded fees were paid.

15. Amendment. No amendment of this Agreement shall be binding on a party unless it is in writing and signed by all the parties. Except for amendments made in compliance with Section 12, above.

16. Assignment. This Agreement, and any rights You may have under it, may not be assigned or transferred by You.

17. Legal Significance. You acknowledge that this Agreement is a legal document and gives the parties certain rights and responsibilities. You also acknowledge that You have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.

18. Miscellaneous. This Agreement shall be construed without regard to any rules requiring that it be construed against the party who drafted the Agreement. The captions in this Agreement are only for the sake of convenience and have no legal meaning.

19. Entire Agreement. This Agreement contains the entire agreement between the parties and replaces any earlier understandings and agreements whether they are written or oral.

20. No Waiver. In order to allow for the flexibility of certain terms of the Agreement, each party agrees that they may choose to delay or not to enforce the other party’s requirement or duty under this agreement (for example notice periods, payment terms, etc.). Doing so will not constitute a waiver of that duty or responsibility. The party will have the right to enforce such terms again at any time.

21. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Pennsylvania. All disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for the CLINIC in Palmyra, PA.

22. Service. All written notices are deemed served if sent to the address of the party written above or appearing in Appendix B by first class U.S. mail.

23. Patient Understandings (initial each):

___ This Agreement is for ongoing primary care and is not a medical insurance agreement.

___ I do NOT have an emergent medical problem at this time.

___ I am enrolling (myself and my family if applicable) in Practice voluntarily.

___ I do NOT have insurance coverage through MEDICARE

___ I understand that neither the Physician nor Practice is Opted-Out of Medicare. Therefore, they are legally required to submit claims to Medicare for covered services for those who have MEDICARE coverage.

___ I DO NOT expect the practice to file or fight any third party insurance claims on my behalf.

___ I understand that I am enrolling in a membership-based practice that will bill me monthly.

___ In the event of a medical emergency, I agree to call 911 first.

___ I understand Physician at Ideal Wellness Family Practice, PC will make every effort to be available but may not always be able to see me on a same-day basis. I may be referred to an urgent care for same-day service.

___ This Agreement does not meet the individual insurance requirement of the Affordable Care Act.

___ This Agreement is non-transferable.

___ I understand failure to pay the membership fee will result in termination from Practice.

The parties may have signed duplicate counterparts of this Agreement on the date first written above.

_____________________________

Jessica Orner, MD for

Ideal Wellness Family Practice, PC

_____________________________ _____________________________

Signature of Patient Name of Patient (printed)

_____________________________

Date

APPENDIX A

SERVICES

1.Medical Services: Medical Services under this agreement are those medical services that the Physician is permitted to perform under the laws of the State of Pennsylvania, are consistent with Physician’s training and experience, are usual and customary for a family medicine physician to provide, and include the following :

• Acute and Non-acute Office Visits

• Well-Woman Care/ Pap Smear

• Chronic Disease Management

• Well-Child Care

• Sports Physicals

• Electrocardiogram (EKG)

• Blood Pressure Monitoring

• Diabetic Monitoring

• Breathing Treatments (nebulizer or inhaler with spacer)

• IUD Removal

• Urinalysis

• Rapid Test for Strep Throat

• Removal of benign skin lesions/warts

• Simple aspiration/injection of joint

• Trigger point injections

• Removal of Cerumen (ear wax)

• Wound Repair and Sutures

• Abscess Incision and Drainage

• Ingrown Toenail Removal

• Basic Vision/Hearing Screening

• Convenience of access to many commonly prescribed medications at reduced prices

• Drawing basic labs. Labs and testing that cannot be performed in-house will be offered through select vendors.

The Patient is also entitled to a personalized, annual in-depth “wellness examination and evaluation,” which shall be performed by the Physician, and may include the following, as appropriate:

• Detailed review of medical, family, and social history and update of medical record;

• Personalized Health Risk Assessment utilizing current screening guidelines;

• Preventative health counseling, which may include: weight management, smoking cessation, behavior modification, stress management, etc.;

• Custom Wellness Plan to include recommendations for immunizations, additional screening tests/evaluations, fitness and dietary plans;

• Complete physical exam & form completion as needed.

2. Non-Medical, Personalized Services. CLINIC shall also provide Patient with the following nonmedical services (“Non-Medical Services”):

a. After Hours Access. Patient shall have direct telephone access to the Physician outside of clinic hours where Patient may reach the Physician directly for guidance regarding concerns that arise unexpectedly after office hours. Patient agrees not to abuse this access. Access may be revoked at any time due to abuse or misuse of the after hours access as determined by the Clinic or Physician.

b. Patient Portal Access. Patient shall have access to a patient portal through which nonurgent communications can be submitted. Such communications shall be dealt with by the Physician or staff member of CLINIC in a timely manner. Patient understands and agrees that email and the internet should never be used to access medical care in the event of an emergency, or any situation that Patient could reasonably expect may develop into an emergency. Patient agrees that in such situations, when a Patient cannot speak to Physician immediately in person or by telephone, that Patient shall call 911 or go to the nearest emergency medical assistance provider, and follow the directions of emergency medical personnel. Access may be revoked at any time due to abuse or misuse of the patient portal as determined by the Clinic or Physician.

c. Timely Appointments. When Patient calls or e-mails the Physician or Clinic, CLINIC shall make every reasonable effort to schedule an appointment for the Patient in a timely fashion.

d. Specialists Coordination. CLINIC and Physician shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the CLINIC Physician.

APPENDIX B

PATIENT ENROLLMENT

Annual fees as set out below shall apply to the following Patient(s), who by signing below agree to the terms and conditions of the Ideal Wellness Family Practice Agreement Form.

¬¬¬¬¬¬¬¬¬____________________________________________________________________________

Printed Name Date of Birth (MM/DD/YYYY) Age

____________________________________________________________________________

Street Address City, State, Zip

____________________________________________________________________________

Home Phone Work Phone Cell Phone Preferred email

____________________________________________________________________________

Spouse Name Date of Birth (MM/DD/YYYY) Age

____________________________________________________________________________

Home Phone Work Phone Cell Phone Preferred email

Child/Children to Whom this Agreement Applies:

____________________________________________________________________________

Print Name Date of Birth (MM/DD/YYYY) Age

____________________________________________________________________________

Print Name Date of Birth (MM/DD/YYYY) Age

____________________________________________________________________________

Print Name Date of Birth (MM/DD/YYYY) Age

____________________________________________________________________________

Print Name Date of Birth (MM/DD/YYYY) Age

I certify that I have read, understand, and agree to the terms set forth in the Ideal Wellness Family Practice, PC Agreement Form. I further certify that I have received a copy of this form.

Signature: __________________________________________________________

APPENDIX C

MEMBERSHIP FEES

Enrollment Fee - This is charged when Patient enrolls with Practice and is nonrefundable. If a patient discontinues membership and wishes to re-enroll in the practice we reserve the right to decline re-enrollment or to require a re-enrollment fee of $200.00.

Monthly Periodic Fee - This fee is for ongoing primary care services.

Initial Enrollment Fee: $75

Monthly Periodic Fees: Individual (per member) Ages: 0-99+ years of age $60 per month ($40 for children with parent/guardian membership)

- OR –

Family Plans (per family)

• $200 per month

• Family is defined as members of a shared household.

• May include 2 adults and 2 children (legal dependents age 25 or less).

• $100 per month: Family of one adult and one child. Each additional child $40

High Risk Medication Management: $40 per month.

Because of the additional monitoring and care involved with managing high-risk medications to ensure patient safety and appropriate prescribing practices, there is an additional $40/month fee for management of these medications. This includes items such as biologics, chronic opioid therapy, and chronic benzodiazepine therapy. This is an optional service. If you do not wish to participate, you are not required to do so. However, without participation, Ideal Wellness Family Practice will not be able to provide prescriptions for high risk substances.