PATIENT AGREEMENT
Concierge Care of Southern Indiana, L.L.C.
This is an Agreement entered into on {date} between Concierge Care of Southern Indiana, L.L.C. ("CCSI") an Indiana Limited Liability Company, located at 500 Lafollette Station Drive, Floyds Knobs, IN 47119, Daniel J. Eichenberger, M.D.,D. Mark Bickers, M.D. and Dr. Christina Minrath ("Physicians") in their capacity as agents of CCSI and you, {printedName} (Patient)
Background
Physicians specialize in Internal Medicine/Peds, and Internal Medicine/Cardiology, respectively, and will deliver care on behalf of CCSI, at the address set forth above. In exchange for certain fees paid by You, CCSI, through Physicians, agrees to provide Patient with the program services described in this Agreement on the terms and conditions set forth in this Agreement.
Definitions
1. Patient. A patient is defined as those persons for whom the Physician shall provide Program Services, and who are signatories to, or listed on the documents attached as Appendix 1, and incorporated by reference, to this Agreement
2. Program Services. As used in this Agreement, the term program services shall mean uninsured medical, non- Medical, and certain benefits, which CCSI offers and specifically described in Appendix 1.
3. Fees. In exchange for the program services, the Patient agrees to pay CCSI, the annual membership fee identified therein. This fee is payable as provided in Appendix 1 and is payment for the program services provided to the Patient during this Agreement.
4. Covered Health Care Services Excluded from Membership Fee. The annual membership fee covers the costs of the program services. The membership fee does not cover the cost of any health care services provided and covered by health insurance or Medicare. Further, fees paid under this Agreement are not covered by your health insurance or Medicare and are not designed or intended as compensation for services covered by such plans.
5. Participation in Insurance. Patient acknowledges that neither CCSI nor the Physicians participate in all health insurance or HMO plans or panels and therefore may be considered a non-participating provider for some plans applicable to the patient. The Patient shall retain full and complete responsibility for any such determination. Nothing in this Agreement supersedes or modifies the terms or conditions of any agreements related to your health insurance. CSSI will, as a convenience to Patient, bill your health insurer or Medicare for all insured health care services. Patient agrees to sign the required Medicare and Medi-Gap Acknowledgment Form attached as Concierge Care of Southern Indiana, LLC. "The Way Medicine Was Meant to Be" Appendix 2 and any assignment of benefits required by any health insurer.
6. Insurance or Other Medical Coverage. Patient acknowledges and understands that this Agreement is not an insurance plan and not intended to replace any existing health insurance or other health plan coverage (such as membership in an HMO) that Patient may carry. This Agreement will not cover hospital services, or any healthcare services not personally provided by CCSI or its Physicians. Patient acknowledges that CCSI has advised Patient to obtain or keep in full force such health insurance policy(ies) or plans that will cover Patient for general healthcare costs.
7. Term; Termination. This Agreement will commence on the date listed in Appendix 1 and auto-renew on a yearly basis unless terminated. Both Patient and CCSI, however, shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination, upon giving 30 days prior written notice to the other party. Unless previously terminated as set forth above, at the expiration of the initial one-year term (and each succeeding yearly term), the Agreement will automatically renew for successive yearly terms upon the payment of the applicable fee.
8. Communications. You acknowledge that communications with the Physician using Email, facsimile, video chat, instant messaging, and cell phone are not guaranteed to be secure or confidential communication methods. As such, you expressly waive the Physician's obligation to guarantee confidentiality with respect to correspondence via such means of communication. You also acknowledge that all such communications may become a part of your medical record. By providing Patient's email address on the attached Appendix 1, Patient authorizes CCSI and its Physicians to communicate with Patient by Email regarding Patient's "protected health information" (PHI) (as that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and it's implementing regulations Patient acknowledges that:
- Email is not necessarily a secure medium for sending or receiving PHI and, there is always a possibility that a third party may gain access.
- Although the Physician will make reasonable efforts to keep email communications confidential and secure, neither CCSI nor the Physician can assure or guarantee the absolute confidentiality
- In the discretion of the Physician, email communications may be made a part of Patient's permanent medical record; and,
- Patient understands and agrees that Email is not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation in which the Member could reasonably expect to develop into an emergency, Member shall call 911 or the nearest Emergency room and follow the directions of emergency personnel.
If Patient does not receive a response to an email message within one day, Patient agrees to use another means of communication to contact the Physician. Neither CCSI nor the Physician will be liable to Patient for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient as a result of technological failures, including, but not limited to, (i) technological failures attributable to any internet service provider, (ii) power outages, failure of any electronic messaging software, or failure to properly address email messages, (iii) failure of the Practice's computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of email communications by a third party; or (v) Patient's failure to comply with the guidelines regarding the use of email communications set forth in this paragraph.
9. Change of Law. If there is a change of any law, regulation or rule, federal, state, or local, which affects the Agreement including these Terms & Conditions, which are incorporated by reference in the Agreement, or the activities of either party under the Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and either party reasonably believes in good faith that the change will have a substantial adverse effect on that party's rights, obligations or operations associated with the Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms of the Agreement including these Terms & Conditions. If the parties are unable to reach an agreement concerning the modification of the Agreement within forty-five days after of date of the effective date of change, then either party may immediately terminate the Agreement by written notice to the other party.
10. 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 that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable.
11. Reimbursement for services rendered. If this Agreement is held to be invalid for any reason, and if CCSI is therefore required to refund all or any portion of the membership fees paid by Patient, Patient agrees to pay CCSI an amount equal to the reasonable value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid.
12. Amendment. No amendment of this Agreement shall be binding on a party unless it is made in writing and signed by all the parties. Notwithstanding the foregoing, the Physician may unilaterally amend this Agreement to the extent required by federal, state, or local law or regulation ("Applicable Law") by sending Patient 30 days advance written notice of any such change. Any such changes are incorporated by reference into this Agreement without the need for signature by the parties and are effective as of the date established by CCSI.
13. Assignment. This Agreement and any rights Patient may have under it may not be assigned or transferred by
14. Relationship of Parties. Patient and Physicians intend and agree that the Physicians, in performing their duties under this Agreement, are independent contractors, as defined by the guidelines promulgated by the United States Internal Revenue Service and/or the United States Department of Labor, and the Physicians shall have exclusive control of their work and the manner in which it is performed.
15. Legal Significance. Patient acknowledges that this Agreement is a legal document and creates certain rights and responsibilities. Patient also acknowledges having had a reasonable time to seek legal advice regarding the Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of the Agreement.
16. Miscellaneous. Physicians reserve the right to treat non-members at their discretion and, if necessary, as long as their obligations to Members are fully satisfied.
17. Entire Agreement: This Agreement contains the entire Agreement between the parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement.
18. Jurisdiction: This Agreement shall be governed and construed under the laws of the State of Indiana, and all disputes arising out of this Agreement shall be settled in a court in Floyd County, Indiana.
19. SERVICE. All written notices are deemed served if sent to the address of the party written above or appearing in Exhibit A by first class U.S. mail.
The parties have signed duplicate counterparts of this Agreement on the date first written above.