DIRECT PRIMARY CARE PATIENT AGREEMENT
We regard the patient-physician relationship with the utmost reverence, and we
thank you for entrusting us with your health care. Communication is at the center of our care, and this Agreement explains how we will work together.
This Agreement is made between Hermitage Direct Primary Care LLC (“Practice”), and You (“You” or “Patient”). Practice offers primary care services in
exchange for certain fees paid by You as described in this Agreement on the terms and conditions described below.
AGREEMENT
1. Services. As used in this Agreement, the term Services means primary care
services and certain amenities (collectively “Services”), which are offered by
Practice.
a. Volume of Services. The number of in-person and virtual visits you may
receive is not limited by this Agreement.
b. Availability. Practice will make every effort to address Your medical needs
in a timely manner, but we cannot guarantee availability, and we cannot
guarantee that You will not need to seek treatment in an urgent care or
emergency department setting under certain circumstances.
c. Included Services.
i. Your membership includes primary care, including well and sick
care, and basic gynecological services. Your physician will make
an appropriate determination about the scope of primary care
services offered by Practice on a case-by-case basis.
ii. Some services available, such as rapid strep tests or
urinalysis, are available at no additional cost to you.
iii. Some services, such as minor surgery, may incur an additional fee (“Itemized Charges”) such as pathology and labwork.
d. Excluded Services. You may need the care of hospitalists, specialists,
emergency rooms, urgent care centers, laboratory testing, radiologic
testing, pathology studies, surgery and specialist consultations, and
dispensed medications, including but not limited to vaccinations, that are
outside the scope of this Agreement. We highly recommend that you
maintain health insurance, which may or may not cover the costs of these
services. Practice will endeavor to place orders for Excluded Services in a
manner that is cost effective for you. Practice will offer you most discounted rates available for these services and medications.
e. Controlled Substances. It is not the policy of Practice to prescribe chronic
controlled substances on Your behalf, including commonly abused opioid
medications, benzodiazepines, and other stimulants. If it is necessary to
prescribe controlled substances for the treatment of your condition, you
will be required to separately sign our Controlled Substance Treatment
Agreement. No controlled substances will be prescribed for longer than 3 days.
f. After-Hours Visits are Subject to the availability of the physician, but we offer after-hours and out of office visits within a radius of
twenty (30) miles of Practice for an additional fee of $100 per visit. There
is no guarantee of after-hours availability.
2. Consent to Treat. You acknowledge and hereby authorize Practice to use
and/or disclose Your health information which specifically identifies You, or which
can reasonably be used to identify You, to carry out Your treatment, payment,
and healthcare operations. Treatment includes but is not limited to: the
administration and performance of all treatments, the administration of any
needed anesthetics, the administration and use of prescribed medication, the
performance of such procedures as may be deemed necessary or advisable for
treatment, including but not limited to diagnostic procedures, the taking and
utilization of cultures, and of other medically accepted laboratory tests, all of
which in the judgment of the attending physician or their assigned designees may
be considered medically necessary or advisable.
3. Scheduling.
a. In order to best serve the needs of all our patients, we prefer that you
schedule Your visit more than 24 hours in advance when possible.
b. Missed Appointments. We kindly request that you provide us with a
minimum of 24 hours notice if you are unable to attend a scheduled
appointment. Your advance notice helps us provide the best possible
experience for all of our patients.
4. Fees. In exchange for Services, You agree to pay Practice
a) the Monthly Fee
b) the Enrollment Fee (Unless waived)
c) any additional Itemized Charges (collectively “Fees”).
In order to remain financially viable, Practice must, and does, reserve
the right to change its fees at any time with thirty (30) days’ notice to you. If it is
necessary for you to pause your membership due to an absence for more than
three (3) months, please speak to Practice administration right away to make
appropriate arrangements.
a. Monthly Fee. Your Monthly Fee is based on your age and identified in the
chart below. This fee is for primary care provided by Practice in the month
for which the fee was received. Your monthly fee is due no later than the
last day of the month and is payable by automatic debit from your bank or
credit card account.
Age Monthly Fee
18-44 YO $50/mo
45-64 YO $75/mo
65+ YO $90/mo
Special Pricing*** First 25 people to sign up for DPC services will get the first 6 months of service for 25 dollars per month and the registration fee will be waived. This is a one time offer
b. Enrollment Fee. Your Enrollment Fee is $99 per individual. If you are
enrolling your immediate family, your Enrollment Fee is capped at $300.
This fee covers the initial administrative cost of your membership and is
not related to the provision of Services. This fee is payable upon
execution of this Agreement and is no longer refundable either five (5)
business days after You sign it, or as soon as you receive Services,
whichever occurs first.
c. Itemized Charges. The fee for Itemized Charges changes in response to
our costs and we endeavor to make these services as affordable as
possible. You will be made aware of the fees for these services in
advance of the services being performed. Payment for these services is
due at the time services are rendered.
5. Disclaimer of Non-Insurance. Fees paid are not health insurance. You
acknowledge and understand that this Agreement is not a health insurance plan,
and not a substitute for health insurance or other health plan coverage, such as
participation in a Health Management Organization (“HMO”). This Agreement is
solely for primary care services provided directly to You by Practice. This
Agreement does not cover hospital, specialist, or any services not directly
provided by Practice. It is highly recommended that You maintain health
insurance for care you may need that is not part of our Services.
6. Non-Participation in Health Insurance. You acknowledge that neither
Practice, nor the Physician(s) will bill any HMO plans, including Medicaid program. Neither Practice nor its Physician(s) make any representations regarding third party insurance reimbursement of fees paidunder this Agreement, and such reimbursement is not anticipated by this Agreement.
7. Non-Participation in Medicaid or medicare. Practice does not accept patients that are beneficiaries of medicare or medicaid until further notice.
8. Medicare Participation. If you are a Medicare beneficiary, or are eligible for
Medicare benefits, you may not enter into this Agreement.
9. Term. This Agreement will commence on the date it is signed by the parties and
shall have an initial term of one (1) month. Upon the expiration of the initial term
this Agreement shall automatically renew for successive monthly terms upon the
payment of the Monthly Fee, until the Agreement is terminated pursuant to the
terms of Section 10.
10.Termination.
Both You and Practice shall have the absolute and unconditional
right to terminate the Agreement, without cause.
a. While we value Your membership, You are under no obligation to continue
receiving Services and You may terminate this Agreement, in writing, at
any time.
b. If you terminate your membership before the end of the month, Your bill
will be prorated based upon the number of days membership was
provided to You, plus any additional Itemized Charges incurred. Once
your membership is terminated, you will not be eligible for any medical
services through Practice, including medication refills. If you decide to rejoin practice You will incur a fee of $350 dollars payable before receiving services
c. Notwithstanding any other provision of this Agreement, if your decision to
terminate is based on a grievance with Practice, You will give us an
opportunity to make it right, prior to issuing Your written notice of
termination or taking other action.
d. If Practice elects to terminate this Agreement, Practice will provide You
with thirty (30) days written notice, or any such other time necessary to
transition Your care to another provider.
e. Practice has a right to determine whom to accept as a patient, just as You
have the right to choose Your physician. There are certain circumstances
in which we may choose to terminate this Agreement. Such
circumstances may include, but are not limited to the following:
i. You fail to pay fees and charges when they are due.
ii. You have performed an act that constitutes fraud.
iii. You fail to adhere to the recommended treatment plan.
iv. You are disruptive, abusive, or present an emotional or physical
danger to the staff or other patients of Practice.
v. Practice discontinues operation.
11.Re-Enrollment. If You choose to discontinue Your membership and You later
wish to re-enroll, Practice reserves the right to decline re-enrollment or require
You to pay a re-enrollment fee that is equivalent to $350 applicable to your membership, excluding discounts.
12.Privacy & Communications.
a. Limited Disclosure. Practice will not disclose your Protected Health
Information (“PHI”) for reasons unrelated to the delivery of Services, or the
provision of other health care services on Your behalf.
b. Your Privacy Rights. Practice will adhere to its obligations regarding your
privacy rights as identified in Practice’s Patient Notice of Privacy
Practices.
c. Methods of Communication. You acknowledge that Practice
communications may include e-mail, facsimile, video chat, instant
messaging, and cell phone, and such communications by their nature
cannot be guaranteed to be secure or confidential. If You initiate a
conversation in which You disclose PHI on any of these communication
platforms, then You authorize Practice to communicate with You regarding
all PHI in the same format.
13.Miscellaneous.
a. Amendment. No amendment or variation of the terms of this Agreement
shall be valid unless in writing and signed by both Parties.
b. Anti-Referral Laws. Nothing in this Agreement, nor any other written or
oral agreement, nor any consideration in connection with this Agreement,
contemplates or requires or is intended to induce or influence the
admission or referral of any patient to or the generation of any business
between Practice and any other person or entity. This Agreement is not
intended to influence any Physician’s professional judgment in choosing
the appropriate care and treatment of patients.
c. Assignment. This Agreement, and any rights You may have under it, are
not assignable or transferable by You.
d. Authorization for Agreement. The execution and performance of this
Agreement by Practice and You have been duly authorized by all
necessary laws, resolutions, and corporate or partnership action, and this
Agreement constitutes the valid and enforceable obligations of the parties
in accordance with its terms.
e. Captions and Headings. The captions and headings for each provision of
this Agreement are included for convenience of reference only and are not
to be considered a part hereof, and shall not be deemed to modify, restrict
or enlarge any of the terms or provisions of this Agreement.
f. Entire Agreement. This Agreement constitutes the entire agreement
between the Parties with respect to the subject matter hereof, and
supersedes any and all other agreements, understandings, negotiations,
or representations, oral or written, between them.
g. Governing Law. This Agreement shall be subject to and governed by the
laws of Tennessee, without regard to any conflicts of law provisions therein
contained. All disputes arising out of this Agreement shall be settled by
binding arbitration. The provider of arbitration services shall be made
solely at Practice’s discretion and costs of arbitration shall be borne
equally by the parties.
h. No Waiver. No waiver of a breach of any provision of this Agreement will
be construed to be a waiver of this Agreement, whether of a similar or
different nature, and no delay in acting with regard to a breach shall be
construed as a waiver of that breach.
i. Non-Discrimination. Under no circumstances will Practice discriminate
against You, or terminate this Agreement, on the basis of sex, race, color,
religion, ancestry, national origin, disability, medical condition, genetic
information, marital status, sexual orientation, citizenship, primary
language, immigration status, or any other protected status. However,
Practice reserves the right to accept or decline patients based upon our
capability to appropriately manage the primary care needs of our patients.
j. Notices. Any notices or payments required or permitted to be given under
this Agreement shall be deemed given when in writing, by electronic
transmission, hand delivered, or with proof of deposit in the United States
mail. All notices shall be deemed delivered on the date of actual delivery,
as evidenced by the return receipt or courier record, or by verified digital
date stamp in the case of electronic transmission.
k. Severability. If any provision of this Agreement shall be deemed, by a
court of competent jurisdiction, to be legally invalid or unenforceable in
any jurisdiction to which it applies, the validity of the remainder of the
Agreement shall not be affected, and the offending 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.
If this Agreement is held to be invalid or unenforceable for any reason,
and if Practice is therefore required to refund all or any portion of the
Monthly Fees paid by You, You agree to pay Practice an amount equal to
the fair market value of the Services actually rendered to You during the
period of time for which the refunded fees were paid commensurate with
prevailing rates in the Practice area.
l. Survival. Any provisions of this Agreement creating obligations extending
beyond the term of this Agreement shall survive the expiration or
termination of this Agreement, regardless of the reason for such
termination.