Membership Medicine Program Agreement
  • Membership Medicine Program Agreement

  • Welcome to ElderHealth’s Membership Medicine Program (the “Program”).  At ElderHealth, we are dedicated to the provision of high quality health care services designed to improve our patients’ well-being, functioning and quality of life.  The Program is designed to meet the unique needs of our patients, including those who are homebound or have chronic conditions or comorbidities, such as heart disease, diabetes, and obesity, with the goal of  reducing our patients’ emergency room and hospital visits.  The Program is also valuable for those who wish to benefit from the extra attention and access to our enhanced services (“Amenities”).    

    This Agreement specifies the terms and conditions under which ElderHealth will offer, and you, the member (Member), will participate in ElderHealth's Membership Medicine Program.

  • Amenities Included in ElderHealth Membership 

    Access to Medical Providers.  We provide same day or next day appointments for urgent health issues. We are available to address your non-urgent concerns during normal business hours and we provide access to one of our providers by telephone after business hours and on weekends for urgent needs. Our multi-disciplinary Provider team spends as much time with each patient as needed to address medical issues to their satisfaction. 

    Coordination of Care.  While every patient of the practice receives coordination of care, members are entitled to concierge-level services, such as communications after hours. In addition, an ElderHealth provider will participate as needed, in patient-provider meetings with Members' specialists.  We are our patients’ advocates and can help you better understand and interpret your specialists’ recommendations.   

    Mobile Notary Services. When a document calls for a notary, we have staff that can come to you to notarize your document(s).

    Try Before You Buy Sensory Modulation Equipment to Manage Behavioral and Psychological Symptoms of Memory Disorders.
    We provide personalized, alternative treatment approaches based on a comprehensive assessment of patient’s identity focusing on medication-sparing, sensory modulation therapy. Using that information, we provide recommendations for products, such as weighted blankets, and give members the opportunity to try the products before they purchase them.

    Art Therapy and Music Therapy. As a member, an initial 1 hr session will be complimentary with our music therapist, and art guide in order to learn about the discipline and see if it's a good fit for you before committing to paying privately for sessions. Complimentary sessions are offered once for the lifetime of the membership, not transferable between people, nor are they able to be split out in 30 minute increments. Sessions following the initial 1 hr complimentary session are paid privately. 

    Caregiver and Family Services.  Resources to detect and treat caregiver burden and improve caregiving success.  Assistance with organization of important patient information and documents. In addition, you will have access to our vetted network of private duty caregivers, home health agencies, elder law attorneys and other community resources. 

    Non-participating Insurance Plans.  As a member, you are not required to pay for services prior to your appointment. Rather, we will request payment after your services are rendered and if/when your insurance has balanced the bill.

     

  • Concierge Medicine Program. The Program is designed to provide you with quality, timely, and highly personalized care.  In exchange for the Membership Fee, our concierge medicine provider will provide you with the Amenities listed above.  The Program and its Amenities may change from time to time with notice to members.  The Amenities are not covered or reimbursed by health care or other insurance plans. 

     
    Annual Membership Fee
    The Annual Membership Fee for the Program covers the Program Amenities listed above for a one-year period. If selecting quarterly payment options, the membership fee for the Program covers the Program Amenities for a 90 day period. The Membership Fee is due when this Agreement is signed by the Member, all subsequent fees are due before the Member’s anniversary date/quarter renewal date. Failure to pay the renewal fee before the anniversary date/quarter renewal date may result in the termination of your membership. The annual Membership Fee is not covered by Medicare or other health care insurance plans and may not be billed to them. The cost for membership for an individual is $1100 per quarter or $4000 annually.  

    Art Guide, Music Therapist, and Nursing/Companionship Fee Any additional visits made by the art guide, music therapist or registered nurse companion are not billed to insurance and are private pay. The member is sent an invoice at the beginning of each month for the previous month's visits and is due on receipt. 

    Rate Increases                                                                                                                        Rates are subject to increase. You will receive at least a (30) day written notice prior to any rate increase.

    No-Show and Cancellation Policy At ElderHealth, we value your time, and we work hard to maintain the flow of visits to our members. Our No-Show policy helps ensure all our members can see the providers as close to their visit times as possible.

    Our no-show and cancellation policy applies to missed visits, which include:

    No-show: If we aren't able to reach you by phone, you fail to join the scheduled telemedicine visit or aren't home for your visit. 
    Late arrival: You arrive 20 or more minutes past your appointment time. (Phone/telemedicine/home visit).
    Late cancellation: You cancel your appointment less than 24 hours before your appointment time.


    We understand there are times when you must miss an appointment due to emergencies. However, missed appointments impact the flow of visits we make to our members. A $50 no-show/late cancellation fee will be billed to you after the second occurrence. If you have a history of three or more missed appointments in a 12-month period, ElderHealth may decide not to treat or see you in the future.

    You can help us ensure all members have the appointment access they need by: 

    • Arriving on time for your appointments (phone/telemedicine/home) visits.
    • Understanding that if it’s 20 or more minutes after your appointment time, we may need to reschedule your appointment.
    • Notifying ElderHealth at least 24 hours in advance if you need to cancel or reschedule your visit. You can notify us of a change or cancellation by phone, email, the patient portal, or by text.

     

    Effective Date and Termination. This Agreement is effective on the date that we receive both your signed written Agreement and payment for the Membership Fee. This Agreement will renew automatically annually (if electing annual membership & quarterly if electing quarterly membership), provided that your Membership Fee is received by the renewal date. Either ElderHealth or the Member may terminate this Agreement for any reason with thirty (30) days written notice to the other party. In addition, ElderHealth may immediately terminate this Agreement with notice to the Member if it elects to discontinue the Program or if there is any change in any federal or state law, regulation, rule, or interpretation that affects our ability to provide the amenities or other services under this Agreement. In the event of termination, you may request a refund. Refunds are issued at the quarterly rate for any unused quarters of your remaining membership fee excluding the first quarter of your membership payment, which is non-refundable. We do not refund current quarter, by day, or prorated quarters.

    Services Not Covered by the Annual Membership Fee
    The Program is not an insurance policy and the Annual Membership Fee covers only the Amenities.  It  does not cover other health care services that ElderHealth may provide to you.  These medical services include, but are not limited to, examinations, laboratory, cognitive and medical tests, radiology, durable medical equipment, and other ancillary services typically provided in a physician office.  ElderHealth will bill your health insurance plan for these services and you will be responsible to pay out of pocket for these and any other services not covered by your insurance plan, including out of network services (e.g., services provided by providers who do not participate in your health insurance plan) and patient deductible and copayment amounts. If you have insurance, your benefits may include some of the Amenities at no additional cost. 


    Communication
    ElderHealth Program providers (“Providers”) will be available to communicate with you 24/7. Providers typically communicate with members by telephone, but members sometimes prefer to communicate using email or text messaging. While we are committed to maintaining the confidentiality of your health information, please know that if we communicate in this manner, we cannot assure the confidentiality or security of the information sent or received. Generally, email and text communications are not secure methods of communicating about your health information and there is some level of risk that the information in the email or text message could be read by a third party. By initiating communications with our practice via e-mail or text or by providing your e-mail and/or text number below, you are authorizing practice personnel to email or text message you despite the potential confidentiality risk.

     

  • If you would like to authorize your Provider to communicate with other individuals related to your health care, please complete ElderHealth’s Authorization to Release Medical Information form and list the individual’s name and contact information below

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Member Cooperation
    For optimal results, it is important that you cooperate with ElderHealth and take initiative regarding your health.  You agree to provide your Program Provider with information regarding your health and changes in your condition or medical history.  The failure to do so may adversely impact your services, and you agree to release ElderHealth from any claims, liability, or damages that may result from your actions.

    Member Responsibilities
    Member or responsible party must be able to provide a safe environment that is clean and uncluttered, be willing and able to provide adequate caregiving for patient safety, provide an environment free of drug and alcohol abuse, provide an environment free of verbal, sexual, physical and financial abuse which we are legally mandated to report, provide a safe place for all firearms with a recommendation to have them in a locked safe and out of view.

    Assignment
    This Agreement is specific to the Member listed below and may not be assigned to any other person.  ElderHealth may assign this agreement to any other provider or practice affiliated with our practice. 

    Governing Law
    This Agreement is governed by and constructed in accordance with the laws of the state of Arizona and supersedes any and all prior written or oral agreements between ElderHealth and the Member.

  •  - -
  • Format: (000) 000-0000.
  • If the Member has a patient representative or health care or financial Power of Attorney, provide the following information:

  • Format: (000) 000-0000.
  • By signing below, you agree to the terms of this Agreement.  

  • Clear
  •  - -
  • Clear
  • Should be Empty: