Dr. Moma Health & Wellness Clinic , P.L.L.C.
DIRECT PRIMARY CARE PATIENT AGREEMENT
This is an Agreement between Dr. Moma Health & Wellness Clinic, P.L.L.C. (“Practice”), a Colorado professional limited liability company and you, the patient (“Patient”).
The Practice employs health care providers (“Providers”), who provide primary care medical and health services on behalf of the Practice.
In exchange for certain fees paid by Patient, the Practice, through its Providers, agrees to provide Patient with the Services described in this Agreement on the terms and conditions set forth in this Agreement. The practice website is www.drmoma.org.
A patient is defined as those persons for whom the Providers shall provide Services, and who agree to be bound by the terms of this agreement. A parent or legal guardian can accept this agreement on behalf of minors in their care.
As used in this Agreement, the term “Services” shall mean a package of ongoing primary care services, both medical and non-medical , and certain amenities, which are offered by Practice, and set forth in Appendix 1. The Patient will be provided with methods to contact Provider via phone, email, and other methods of electronic communication. Provider will make every effort to address the needs of the Patient in a timely manner, but cannot guarantee availability, and cannot guarantee that the patient will not need to seek treatment in the urgent care or emergency department setting.
In exchange for the services described herein, Patient agrees to pay Practice the amount as set forth in Appendix 1, attached. If this Agreement is terminated by either party before the end of an applicable monthly period, then the Practice shall seek only partial payment for the final month of service based on the number of days of membership provided to the patient and the itemized charges, set forth in Appendix 1, for services rendered to Patient up to the date of termination. Fees are subject to change in the future, but Patient will be provided ninety (90) days’ notice prior to any fee change taking effect.
Non-Participation in Insurance.
Patient acknowledges that neither Practice, nor the Providers participate in any health insurance or HMO plans. Neither the Practice nor Providers make any representations regarding third party insurance reimbursement of fees paid under this Agreement. The Patient shall retain full and complete responsibility for any such determination.
Insurance or Other Medical Coverage.
Patient acknowledges and understands that this Agreement is not an insurance plan, 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 its Providers. Patient acknowledges that Practice has advised that patient obtain or keep in full force such health insurance policy(ies) or plans that will cover Patient for general healthcare costs. Patient acknowledges that THIS AGREEMENT IS NOT A CONTRACT THAT PROVIDES HEALTH INSURANCE, in isolation 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 may carry. This Agreement is for ongoing primary care, and the Patient may need to visit the emergency room or urgent care from time to time. Physician will make every effort to be available during business hours via phone, email, other methods such as “after hours” appointments when appropriate, but Provider cannot guarantee 24/7 availability.
This Agreement will commence on the date it is accepted by Patient and will extend monthly thereafter. Notwithstanding the above, both Patient and Practice shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination. The Patient may terminate the agreement with twenty-four hours prior notice, but the Practice shall give thirty days prior written notice to the Patient and shall provide the patient with a list of other Practices in the community in a manner consistent with local patient abandonment laws. Unless previously terminated as set forth above, at the expiration of the initial one-month term (and each succeeding monthly term), the Agreement will automatically renew for successive monthly terms upon the payment of the monthly fee at the end of the contract month. Examples of reasons the Practice may wish to terminate the agreement with the Patient may include but are not limited to:
The Patient fails to pay applicable fees owed pursuant to Appendix 1 of this Agreement;
The Patient has performed an act that constitutes fraud;
The Patient repeatedly fails to adhere to the recommended treatment plan, especially regarding the use of controlled substances;
The Patient is abusive, or presents an emotional or physical danger to the staff or other patients of Practice;
Practice discontinues operation; and
Practice has a right to determine whom to accept as a patient, just as a patient has the right to choose his or her physician. Practice may also may terminate a patient without cause as long as the termination is handled appropriately (without violating patient abandonment laws).
Privacy & Communications.
You acknowledge that communications with the Providers using e-mail, facsimile, video chat, instant messaging, and cell phone are not guaranteed to be secure or confidential methods of communications. The Practice will make an effort to secure all communications via passwords and other protective means as recommended by standard HIPAA regulations and practices. The Practice will make an effort to promote the utilization of the most secure methods of communication, such as software platforms with data encryption, HIPAA familiarity, and a willingness to sign HIPAA Business Associate Agreements. This may mean that conversations over certain communication platforms are highlighted as preferable based on higher levels of data encryption, but many communication platforms, including email, may be made available to the patient. If the Patient initiates a conversation in which the Patient discloses “Protected Health Information (PHI)” on one or more of these communication platforms then the Patient has authorized the Practice to communicate with the Patient regarding PHI in the same format.
If for any reason any provision of this Agreement shall be deemed legally invalid or unenforceable by a court of competent jurisdiction, 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.
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 Patient, Patient 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.
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. We may decline new patients pursuant to the guidelines proffered in Section 6 (Term), because the Physician’s panel of patients is full (capped at 800 patients or fewer), or because the patient requires medical care not within the Provider’s scope of services.
This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient.
This Agreement shall be governed and construed under the laws of the State of Colorado and all disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for the Practice address in Colorado Springs, CO.
a. This Agreement is for ongoing primary care and is NOT a medical insurance agreement.
b. I do NOT have an emergent medical problem at this time.
c. In the event of a medical emergency, I agree to call 911 first.
d. I do NOT expect the practice to file or fight any third party insurance claims on my behalf.
e. I do NOT expect the practice to prescribe chronic controlled substances on my behalf. (These include commonly abused opioid medications, benzodiazepines, and stimulants.)
f. In the event I have a complaint about the Practice I will first notify the Practice directly.
g. This Agreement (without a “wrap around” compliant insurance policy) does not meet the individual insurance requirement of the Affordable Care Act.
h. I am enrolling myself (and my family if applicable) in the practice voluntarily.
i. I may receive a copy of this document upon request.
j. This Agreement is non-transferable.
DR. Moma Health & Wellness Clinic Periodic Fees and Services- This Agreement is for ongoing primary care. This is Agreement is NOT HEALTH INSURANCE and isNOT A HEALTH MAINTENANCE ORGANIZATION. The Patient may need to use the care ofspecialists, emergency rooms, and urgent care centers that are outside the scope of this Agreement.Each Provider within the Practice will make an appropriate determination about the scope ofprimary care services offered by the Provider.. Examples of common conditions we treat,procedures we perform, and medications we prescribe are listed on our website and are subject tochange.
Monthly Periodic Fee (billed at the end of the service period)This fee is for ongoing primary care services. There is no cap for the number of in-office visits orvirtual visits (e-mail, electronic, phone). We prefer that you schedule visits more than 24 hours inadvance when possible.
The monthly periodic fee is $79.00 per month for individuals ages 18 and up, Family plan of three $150 and $50.00 per month for individuals ages 0 through 18 (due at the end of the month of service). Fees are subject to change in the future, but Patient will be provided ninety (90) days’ notice prior to any fee change taking effect.
The periodic fee will be billed at the end of the month (after the ongoing primary care has been provided) and the Patient is entitled to leave the practice at any time and be assigned a prorated final bill based upon the date of withdrawal from the practice.
Re-Enrollment Fee. If a Patient cancels their monthly membership with Practice, and later wishes to re-enroll as a Patient, a re-enrollment fee of $200 will be assessed.
After-Hours Visits. There is no guarantee of after-hours availability. This agreement is for ongoing primary care, not emergency or urgent care. Your provider will make reasonable efforts to see you as needed after hours if your pprovider is available.
Ongoing Primary Care is included with the Periodic Fee described herein. Please see a list of some of the chronic conditions we routinely treat on the Practice website (subject to change). There are no itemized fees for office visits.
In-Office Procedures we are generally comfortable performing are listed on the Practice website. These are typically available at no additional cost unless otherwise designated, and these are also subject to change.
Ancillary Services. Some ancillary services will be passed through “at cost” (no markup by us). Examples of theseancillary services include laboratory testing and radiologic testing. These are described below.Many services available in our office (such as EKGs) are available at additional cost to you. Itemsavailable at no additional cost will be listed on our website and are subject to change.
Medications. Patient may request that we submit your prescriptions to a pharmacy of your choice for cash pay or filing with your separate insurance policy.
Laboratory Studies will be charged according to the direct price rate we have negotiated with the lab. An example of common laboratory studies and their prices (subject to change) are listed on the practice website. Pathology studies will be ordered in the most economical manner possible. Anticipated prices for these studies (subject to change) are listed on the Practice website.
Radiology studies will be ordered in the most cost effective manner possible for the Patient. Commonly ordered radiologic studies and prices (subject to change) are listed on the website.
Surgery and specialist consults will be ordered in the most cost effective manner possible for the Patient. Patient will be responsible for costs incurred for these services. The Practice strongly encourages Patient to maintain a high health insurance policy to cover these costs, should they arise.
Vaccinations Some are offered in our office at this time due to the cost prohibitive nature of stocking
a limited supply. We will make an effort to help you obtain needed vaccinations elsewhere if not available in the office, in the most cost effective manner possible.
Hospital Services are NOT covered by our membership plan, and due to mandatory “on call” duties required at local institutions we have elected NOT to obtain formal hospital admission privileges at
Obstetric and Gynecologic Services are NOT covered by our membership plan. In the future we may begin to offer some of these outpatient services in our office, but due to our small size we are unable to offer these services at this time.