This is an Agreement between Up North Pediatrics, PLC (the “Practice”), Dr. Amy Couturier (“Physician”) as an agent of the Practice; and the parent(s) and/or legal guardian(s) (collectively, “Parent”) of a minor (“Patient”) whose names are set forth below. This Agreement is intended to be a direct primary care agreement and is not anagreement for insurance or other healthcare coverage.

Definitions

1. Patient. A Patient is defined as those persons for whom the Practice shall provide Services, and who are signatories to, or, in the case of minor children, identified by name below by Parent, and for whom the provision of Services has been authorized and consented to by Parent.

2. Services. The term “Services” shall mean a package of ongoing primary care services, both medical and non-medical, and certain amenities whichare offered by Practice to Patient and set forth in Appendices 1 and 2.. Physician will make reasonable efforts to be available to Parent or Patient at all times via phone, email, and other methods such as “after hours” appointments when appropriate, but
neither the Practice nor Physician can guarantee “24/7” availability. Parent agrees that Patient may need treatment in an urgent care or emergency department setting, when the Practice and/or Physician are unavailable.

Terms

3. CONSENT FOR MEDICAL TREATMENT OF A MINOR. By executing this Agreement, Parent warrants that Parent is the parent and/or legal guardian of Patient, a minor child. Parent hereby consents and gives permission for Patient to receive medical treatment from a provider at the Practice (including but not limited to Physician), and with or without Parent present. Treatments may include, among others, immunizations and any examinations or other procedures deemed medically necessary by the treating provider. This consent does not expire unless revoked in writing.

4. FEES. In exchange for the Services, Parent agrees to pay Practice the amount set forth in Appendices 1 and 2, attached. Parent will pay fees monthly in advance, on or before the1st day of each month. Practice may adjust its fees at any time, and will give Parent at least 30 days notice of changes in monthly fees. Laboratory tests, prescription drugs, and other services provided by Practice and which are charged to Parent in addition to monthly fees may be changed from time to time and will be posted on Practice’s website. Parent understands that in addition to the monthly fee described above, Practice may charge to Parent administrative fees for certain services associated with the establishment and maintenance of Parent or Patient’s account, or additional fees for certain services that are not covered by the monthly fee (e.g., out of area house call fees). Parent agrees to pay all such fees no later than thirty (30) days after they are incurred. 

5. NON-PARTICIPATION IN INSURANCE. Parent acknowledges that neither Practice nor Physician participates in any health insurance, HMO, or other third-party payor plans. By signing this agreement, Parent acknowledges and understands that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for Patient or Parent by the Physician. Parent agrees not to bill Medicare or attempt Medicare reimbursement for any such services. Parent acknowledges that federal regulations require that Physician opts out of Medicare so that Medicare patients may be seen by the Practice pursuant to this private direct primary care contract. Neither the Practice nor Physician makes any representations regarding third-party insurance reimbursement of fees paid under
this Agreement, which shall not be the Practice or Physician’s responsibility.

6. OTHER MEDICAL COVERAGE. Parent acknowledges that this Agreement is not an insurance plan or contract for health insurance, and not a substitute for health insurance or other health plan coverage such as membership in an HMO. It will not cover hospital services, or any services not personally provided by Practice or the Physician. Practice advises that Patient and Parent obtain or keep in full force such health insurance policies or plans that will cover Patient for general healthcare
costs. This Agreement does not meet the insurance requirements of the Affordable Care Act, and is not intended to replace any existing or future health insurance or health plan coverage that Patient or Parent may carry. This Agreement is for ongoing primary care only, and does not include all services that Patient may need, such as emergency room or urgent care services, X-rays or some diagnostic tests. Fees paid to Practice under this Agreement shall not cover such outside services.

7. TERM. This Agreement begins on date it is signed by Parent and Physician and will extend monthly thereafter. Both Parent and Practice shall have the unconditional right to terminate the Agreement, with or without cause. Parent may terminate the Agreement at any time by written notice, but the Practice shall give thirty days prior written notice to the Parent, and shall provide Parent with such assistance as is required by law and Physician’s ethical duties. At the expiration of the each one-month term, the Agreement will automatically renew for successive monthly terms upon the payment of the monthly fee at the beginning of the contract month. Upon termination of this Agreement by Parent, fees already paid to Practice will not be prorated or refunded, and billing for Services will cease at the expiration of the current Agreement term. Examples of reasons the Practice may wish to terminate the Agreement with the Patient may include but are not limited to:

(a) Parent fails to pay any fees owed under this Agreement;
(b) Parent has performed an act that constitutes fraud, or otherwise made any
misrepresentations to Physician or the Practice, including without limitation Parent’s
right to provide consent for treatment of Patient;
(c) Patient misses scheduled appointments on three occasions without providing 24 hour advance notice of cancellation;
(d) Patient and/or Parent repeatedly fails to adhere to the recommended treatment plan, especially regarding the use of controlled substances;
(e) The Patient and/or Parent is physically or emotionally threatening to Physician or other patients or Practice staff;
(f) Physician determines that the clinical relationship between Patient and Physician
cannot or should not continue; or
(g) Practice discontinues operation.

8. COMMUNICATIONS. Parent acknowledges that communications with the Physician using e-mail, facsimile, video chat, instant messaging, and cell phone are not guaranteed to be secure or confidential. If the Patient or Parent sends correspondence containing “Protected Health Information” or other confidential consumer information, this shall serve as consent and authorization for the Practice to communicate with the Patient and/or Parent in the same format or
medium.

9. SOCIAL MEDIA. If Patient or Parent consents to the Practice making a photographic, video, or audio recording of Patient, Patient and Parent agree and freely give Practice the consent and right to use such images, recordings, or likenesses, without limitation, in promotional, marketing, or other informational materials of the Practice’s choosing. This consent shall specifically extend to and
include the Practice’s use of such likenesses, photographs, or recordings for the Practice’s social media account(s) of any kind or nature. Parent and Patient waive all claims that either may have or acquire against Practice, in connection with Practice’s use of such photographs, recordings, images, and/or likenesses. This consent may be revoked prospectively only, in writing delivered to Practice.

10. SEVERABILITY. If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be invalid or unenforceable, the validity of the remainder of the Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall
then be enforceable.

11. Reimbursement for Services if Agreement is Invalidated. If this Agreement is held to be invalid for any reason, and if Practice is therefore required to refund all or any portion of the monthly fees paid by Parent, Parent agrees to pay Practice an amount equal to the fair market value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid.

12. Assignment. This Agreement, and any rights Patient and/or Parent may have under it, may not be assigned or transferred by Patient or Parent.

13. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Michigan. The parties consent to the jurisdiction of the Grand Traverse County Circuit Court (or District Court, as applicable) for any dispute arising out of this Agreement or the provision of the Services, and agree that venue shall be exclusively proper in Grand Traverse County.

14. Indemnification. Parent hereby indemnifies and holds harmless Physician, Practice, and its member(s), officers, employees, against any losses, claims, damages, or liabilities to the extent that they are caused by an act or omission of Parent or Patient. This includes, but is not limited to, liabilities, damages, or claims arising out of Parent’s breach of any provisions of this Agreement, including any misrepresentations regarding Parent’s custodial relationship with Patient, and/or Parent’s ability to consent to the treatment of Patient by the Practice or Physician.

APPENDIX 1

Up North Pediatrics Periodic & Enrollment Fees

Fee Schedule

 

Monthly Periodic Fee (billed at the beginning of each month) – This fee is for ongoing primary care services. All in-office and virtual visits are included in the fee. Some ancillary services will be passed through based on the prices we negotiate with third-party service providers. Examples of these ancillary services include laboratory testing and dispensed medications. These are described in Appendix 2. Many services available in our office are available at no additional cost to you. Items available at no additional cost will be listed on our website and are subject to change. 

The monthly periodic fee is due when request is sent and monthly thereafter. 

The periodic fee will be billed monthly from the last payment and Patient is entitled to discontinue their membership at any time. If the Patient’s enrollment is terminated, Patient will retain access to Up North Pediatrics through the end of their monthly billing period and no furthercharges will be collected. 

 

After-Hours Visits 
There is no guarantee of after-hours availability. This Agreement is for ongoing primary care, not emergency or urgent care. However, Physician will make reasonable efforts to see the Patient as needed after hours, if the Physician is available.

Acceptance of Patients We reserve the right to accept or decline patients based upon our capability to appropriately handle the patient’s primary care needs. The Practice may decline new patients for any reason not prohibited by law, at the sole discretion of Practice and Physician.

APPENDIX 2

Up North Pediatrics – Services Subject To Itemized Fees

Ongoing Primary Care is included with the Periodic Fee described in Appendix 1. This includes preventative care: physical exams, health maintenance, and nutrition and exercise counseling. There are no itemized fees for office visits.

Home Visits are offered at Physician’s discretion and depending in part on distance from the Practice’s clinic, with an exception for babies for their first home visit, for which home visits are included with monthly periodic fee.

In-Office Procedures. We provide minor incision and drainage of abscess, minor wound treatment including glue, staple, and basic suture repair, wart treatments including canthardin and cryotherapy and tongue tie releases or frenulectomy are available at no additional cost unless otherwise designated, and these are also subject to change. If there are circumstances in which we feel we cannot provide those procedures on an in-office basis, we will inform Patient and/or Parent, and assist with finding appropriate care settings. In-office testing, including urinalysis, strep tests, urine pregnancy tests, and blood sugar tests are available at no additional cost. The list of available in-office tests (subject to change) is on the practice website.

Laboratory Studies that we can perform may be drawn in the office and the Patient and/or Parent will be charged based on prices we have negotiated with the laboratory. An example of common laboratory studies and their prices (subject to change) are listed on the practice website. If the Practice cannot perform the laboratory studies, the Practice will work with the Patient to determine the best way to perform the laboratory study.

Medications will be ordered in the most cost effective manner reasonably possible. When we dispense medications in the office,these medications will be made available to the Patient based on the wholesale cost we have negotiated with the distributors. Examples of commonly dispensed medications and their prices (subject to change) are listed on the practice website. 

Pathology studies are not done in our clinic and appropriate referral will be made.

Radiology studies will be ordered in the most cost effective manner reasonably possible for the Patient. These are not included in monthly fees.

Surgery and specialist consults will be ordered in accordance with patient preferences. These are not included in monthly fees.

Vaccinations may be offered in our office from time to time, although we currently have a limitedset of options available. In the event a recommended vaccine is not available in the office, we willassist you in obtaining vaccines in a cost effective manner. These are not included in monthly fees. 

Hospital Services are not covered by our primary care agreement, and we have elected not to obtain formal hospital admission privileges at this time. We will work with Patients to coordinate care in a cost-effective manner if the Patient requires inpatient stay or other hospital procedures. 

Obstetric (pregnancy) Services are NOT covered by our primary care agreement. We will work with youto identify an obstetric specialist if needed, and coordinate care with that specialist.

Patient/Parent Acknowledgements:

 

I understand that I am responsible for paying the monthly fees and other costs in this Agreement, and that if I do not pay the fees required in this Agreement will terminate and Practice will no longer provide primary care services to or for Patient.

Patient does not have an emergent medical problem at this time.

In the event of a medical emergency, I agree to call 911 first or seek care for Patient at an emergency room or other appropriate location. I understand that this Agreement does not include emergency medical care for Patient.

I do not expect the Practice to file, negotiate, or contest any third-party insurance claims on my behalf or on behalf of Patient. Iwill not submit any claims to third-party insurers for services that Patient or I receive from the Practice, whether on an out-of-network basis or otherwise.

I understand that I will be responsible for all costs of healthcare services for Patient received outside of the Practice. This includes costs of pharmaceuticals prescribed to me or Patient by Physician, or other treatments or tests recommended by Physician that Patient cannot obtain at the Practice.

I understand that Practice only prescribes chronic controlled substances in extremely limited circumstances, and only when the Physician feels they are clinically indicated and there are no other medically sound alternatives.

In the event I have a complaint about the Practice I will first notify the Practice directly, and attempt to resolve my concerns with the Practice before pursuing other redress. 

I UNDERSTAND THAT THIS AGREEMENT IS NOT HEALTH INSURANCE, IS NOT SUBJECT TO THE INSURANCE LAWS OF THE STATE OF MICHIGAN, AND DOES NOT MEET ANY INDIVIDUAL HEALTH INSURANCE MANDATE THAT MAY BE REQUIRED UNDER STATE OR FEDERAL LAW.