DIRECT PRIMARY CARE PATIENT AGREEMENT
Direct Family Care of Northern Colorado, PLLC
This is an Agreement between Direct Family Care of Northern Colorado, PLLC (Practice) a Colorado LLC located at 126 W. Harvard Ste 1 Fort Collins Colorado, Jennifer McCabe Lentz, MD (Physician) in her capacity as an agent of Direct Family Care of Northern Colorado and You (Patient).
The Physician practices family medicine and delivers care on behalf of Direct Family Care of Northern Colorado, PLLC in Fort Collins, CO. In exchange for certain fees paid by Patient, the Practice, through its Physician, 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 https://www.directfamilycareofnoco.com
Definitions: 1. Patient: Patient is defined as those persons for whom Physician shall provide Services, and who are signatories to and incorporated by reference to this agreement.
2. Services: 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 (collectively Services), which are offered by Practice, and set forth in Appendix 1. Patient will be provided with methods to contact the physician via phone, email, and other methods of electronic communication. Physician 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.
3. Fees: In exchange for the services described herein, Patient agrees to pay Practice the amount as set forth in Appendix 1, attached. Applicable enrollment fees are payable upon execution of this agreement. Any and all disputed charges will be charged at least $20 min. If the disputed charge is more than $20 a 10% surcharge on top of the existing fee will be added. Patient will be notified 30 days in advance of any fee changes. If the Patient is cash pay only we require 3 months payment at time of service.
4. Non-Participation in Insurance: Patient acknowledges that neither Practice nor the Physician participate in any health insurance or HMO plans. Dr. Lentz has opted out of Medicare. Patient acknowledges that federal regulations REQUIRE that Physician opt out of Medicare so that Medicare patients may be seen by the Practice pursuant to this private direct primary care contract. Neither Practice nor Physician make any representations regarding third party insurance reimbursement of fees paid under this Agreement. Patient shall retain full and complete responsibility for any such determination. If Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, then Patient will sign the agreement attached as Appendix 2, and incorporated by reference. This Agreement acknowledges your understanding that Physician has opted out of Medicare, and as a result, Medicare cannot be billed for reimbursement for any such services. Due to Colorado law neither Practice nor Physician may care for people with Colorado state Medicaid.
5. 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 the Practice or its Physician. Patient acknowledges that the Practice has advised that Patient obtain or keep in full force such health insurance policy(ies) or plans that will cover Patient for general health care 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 Patient may need to visit the emergency room or urgent care from time to time. Physician will make every effort to be available via phone, email and other methods such as “after hours” appointments when appropriate, but Physician cannot guarantee 24/7 availability.
6. Disclaimer: This agreement does not provide health insurance coverage, including the minimal essential coverage required by applicable federal law. It provides only the services described herein. It is recommended that health care insurance be obtained to cover medical services not provided for under this direct primary care agreement.
7. Term: This Agreement will commence on the date it is signed by Patient and Physician below 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. Patient may terminate the agreement with twenty-four hours prior notice, but Practice shall give thirty days prior written notice to Patient and shall provide Patient with a list of other practices in the community in a manner consistent with local patient abandonment laws.
Reasons Practice may terminate the agreement with the Patient may include but are not limited to:
(a) Patient fails to pay applicable fees owed pursuant to Appendix 1 per this Agreement;
(b) Patient has performed an act that constitutes fraud;
(c) Patient repeatedly fails to adhere to the recommended treatment plan, especially regarding the use of controlled substances;
(d) Patient is abusive, or presents an emotional or physical danger to the staff or other patients;
(e) Practice discontinues operation; and
(f) 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.
(g) Practice may also may terminate a Patient without cause as long as the termination is handled appropriately (without violating patient abandonment laws).
8. Privacy & Communication: You acknowledge that communications with Physician using e-mail, facsimile, video chat, instant messaging, and cell phone are not guaranteed to be secure or confidential methods of communication. Practice will make an effort to secure all communications via passwords and other protective means and these will be discussed in an annually updated Health Insurance Portability and Accountability Act (HIPAA) “Risk Assessment.” 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 Patient. If Patient initiates a conversation in which Patient discloses “Protected Health Information (PHI)” on one or more of these communication platforms then Patient has authorized Practice to communicate with Patient regarding PHI in the same format.
9. Severability. If for any reason 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 that provision shall be deemed modified to the minimum extent necessary to make the provision consistent with applicable law and in its modified form, and that provision shall then be enforceable.
10. 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 Services actually rendered to Patient during the period of time for which the refunded fees were paid.
11. Assignment: This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient.
12. Jurisdiction: This Agreement shall be governed and constructed 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 Practice address in Fort Collins, Colorado.