This Professional Services Agreement (Agreement) sets forth the conditions under which ELDERCONSULT, INC., a California professional S-Corporation; (ElderConsult) will provide primary care medical services to the individual named above (You).

1. Primary Care / Expanded Coverage Medical Service

• A personal medical doctor (MD) who knows you and your medical situation on call 24 hours a day for urgent care concerns.
  
  
• Initial Assessment made by MD and report sent to your Primary Care Physician and Family/Responsible Party.
  
  
• Office/Administrative support available Monday through Friday 9:00am - 5:00pm
  
  
• Follow up by ElderConsult MDs as needed.
  
  
• Referrals to specialists, if not an HMO patient.
  
  
• Referrals and administrative support for Home Health, if not an HMO patient.
  
  
• Referrals and administrative support for Hospice, if not an HMO patient.
  
  
• If ElderConsult providers are prescribing anti-psychotic or other serious psychoactive medications and/or narcotics, it is understood that you will automatically be signed up for the Expanded Care Coverage Services of ElderConsult Geriatric Medicine and will need to be seen at a minimum of once every two months.
  
  
• ElderConsult will order (but not provide) laboratory tests, X-rays, or other diagnostic services and prescription refills as needed in MD’s discretion, if not limited by HMO rules.

Availability:

• MD’s endeavor to be available to see patients as soon as possible after receiving your call. They may not be able to make a house call for each event. However, they will speak with the Emergency Room doctor to coordinate care if needed.
  
  
• Your personal MD will be available by phone for urgent medical concerns. If a call back has not been received in 30 minutes and the concern is urgent, call 911.

Scheduling Appointments:

• Call ElderConsult at 650-357-8834 x 1 to arrange an appointment or leave a message stating your name, phone number, and date you would like an appointment.
  
  
• ElderConsult will generally respond to your message that business day for issues related to the evaluation. For urgent medical issues you can call your ElderConsult physician. For non-urgent issues leave a message in the portal.
  
  
• Do not wait for ElderConsult to return your call if you are having an emergency. Instead, seek immediate medical attention by calling 911 and going to the closest emergency room.

Alternative Care Issues:

• You are responsible for arranging alternative care when ElderConsult providers are unavailable to make a house call. Although our providers may be available to make after-hours house calls, if they are unavailable and you desire or require immediate medical attention, you should seek medical care from an Urgent Care center or hospital Emergency Room, as appropriate. In the event you seek such alternative care, please call your ElderConsult provider to alert her to call the hospital Emergency Room to be informed of your current medical condition. ElderConsult and our providers are not responsible for the type or quality of care rendered to you by other providers.
  
  
• ElderConsult does not have any professional staff affiliations with other physicians, physician groups or hospitals. Neither ElderConsult nor our providers provide any referrals to other providers of primary medical care services.
  
  
• Our providers do not have staff privileges at any area hospitals and cannot serve as your admitting physician. If you require hospitalization, you must obtain services from a qualified physician with hospital admitting privileges. Such services may be obtained through a physician’s private practice or through a hospital Emergency Room. However, if notified, ElderConsult providers will consult with and coordinate your hospital care with the admitting physicians.

2. Consulting Services

• Capacity evaluation

3. Capacity Evaluation: Elder Abuse

• When requested, ElderConsult will provide a capacity evaluation in the scope of the Geriatric Medical Practice. We will work with the elder and involved legal advocates to address issuesof financial and other elder abuse. ElderConsult does not provide legal advice, but referrals to government resources as needed for further intervention.

4. Conduct of Practice

ElderConsult Professionals and Our Providers Will Conduct Their Practice to:

• Combine focused knowledge of your condition with extensive experience in care of older adults with complex care needs, integrating knowledge of your family and of your facility (where applicable) and other sources of information, and
  
  
• Emphasize expert geriatric care with the goal of maximizing health, quality of life, and avoiding excess medications.

5. Payment

ElderConsult will charge you on a fee-for-service basis for the services it provides to you. ElderConsult will provide a schedule of services and the fees charged for those services upon your request. That schedule is subject to revision from time to time.

• Payment by cash, check, credit card, or money order is due at the time of service unless the parties agree to a different arrangement.
  
  
• In the event any remaining or additional charges are billed later than the date of service, you will be billed for any balance due. Upon receipt of the statement billing for remaining charges, payment may be made over the telephone by credit card or you may mail your check upon receipt of the statement.
  
  
• Please note that if payment is not received within thirty (30) days from the statement billing date, then your credit card on file will be charged for the balance then due. If payment is not received within 60 days, there will be a 5% penalty applied to the outstanding balance every 30 days, until paid in full or other arrangements are made with Elder Consult.
  
  
• ElderConsult may terminate this Agreement immediately if you are delinquent in your account with ElderConsult.
  
  
• At its sole discretion, ElderConsult may employ a sliding fee scale to provide lower fees for financially distressed patients, after approval and receipt of requested documentation and payment arrangement.

6. Insurance

• ElderConsult and our providers do NOT accept Medicare, Medicare Supplements, Medi-Cal, Worker’s Compensation, HMO plans, or any form of private insurance that is dependent on Medicare.
  
  
• You are solely responsible for payment of charges in full. If you have insurance of a type otherthan those listed above, (e.g., a PPO) then ElderConsult will submit a claim to that insurer for you as a courtesy. However, it will be your responsibility to follow up on any such claim with your insurance provider.
  
  
• If the insurance company does make a payment, it will be applied towards any outstanding balance on your account. Otherwise, any unused portion of any payment received from insurance will be reimbursed to you.

By signing below, you agree to all the terms and conditions of this Agreement including agreement to pay for all services rendered and confirm your understanding that ElderConsult does not accept any form of health insurance.

7. Confirmation

If signed by someone other than the patient, the individual signing below represents and warrants to ElderConsult that he or she has the legal authority to execute this Agreement on the patient’s behalf.

v.9-2020 ­— Professional Services Agreement