This Agreement outlines the terms of your Weight Journey Program (the "Program") offered by true Women’s Clinic of Grand Rapids, PC (the “Practice”).
The Program is designed with you in mind and to provide you Personalized Care Enhancements (“Enhancements”) including convenient access to the true. Team (“Team”) and Professional Medical Services.
Enhancements: In consideration for your payment of the Annual Fee ($900), the Practice will provide you the Enhancements set forth below, to the extent such Enhancements are not covered by your insurance.
By signing this Agreement, you agree to pay the Practice the Annual Fee described in this section. For clarification, the Annual Fee only pays the Practice for providing you the Enhancements. The Annual Fee is not intended to, and does not, pay for any professional or related services that are provided by the Practice or the Team that are covered by Your health insurance plan; and the Practice will not seek reimbursement from Medicare or any health insurance plan for these Enhancements.
Professional Medical Services: In addition to providing and/or overseeing some of the Enhancements described above, the Team will be available to provide You professional medical services that are covered by your health insurance plan in the area of weight management.
The Practice will bill you or, if appropriate, will bill your health insurance plan, separately, for professional or related services rendered to you by the Practice or your Physician that are covered by Your health insurance plan, unless otherwise specified.
The Practice currently participates with many major health plans, but does not participate with Medicare or Medicaid. By participating in a health plan, the Practice accepts payment from those plans for covered professional services, subject to applicable deductibles, co-payments and co-insurance, which are Your responsibility. The Practice recommends that you maintain in effect any health insurance you currently have.
Your health benefit plan may or may not provide coverage for all of the health care services you are scheduled to receive or the providers providing those services. You may be responsible for the costs of the services that are not covered by your health benefit plan. We will provide a good-faith estimate of the cost of those services. You have a right to request that the health care services be performed by a provider that participates with your health benefit plan, and may contact your carrier to arrange for those services to be provided at a lower cost and to receive information on in-network providers who can perform the health care services that you need.
Payment Terms: Your initial Annual Fee (One-time payment ($900.00) or monthly payment of $75.00) is due at the time you sign this Agreement. This Agreement will renew annually unless otherwise terminated. The Practice reserves the right to change the Annual Fee at any renewal date of this Agreement, by giving you at least thirty (30) days’ advance written notice. You understand and agree that this Agreement is a service contract and not a contract of insurance, and you understand that you are not required to enter into this Agreement. You further agree not to submit a claim to any commercial or government health insurance plan (including Medicare) for any of the Enhancements. While you may, in your discretion, submit the Annual Fee for reimbursement to a flexible spending account, health reimbursement account, or medical savings account in which you participate, the Practice makes no representation that any part of the Annual Fee will qualify to be reimbursed from any such account.
You authorize the Practice and the Team to communicate with You by e-mail regarding your “protected health information” (“PHI”) (as that term is defined in the Health Insurance Portability and Accountability Act (“HIPAA”) of 1996 and its implementing regulations) using Your e-mail address shown below. In so agreeing, You acknowledge that: e-mail is not a secure medium for sending or receiving PHI; although the the Practice and the Team will make reasonable efforts to keep e-mail communications confidential and secure, neither the Practice, nor the Team, can assure the confidentiality of e-mail communications; and, in the discretion of the Practice and/or your Physician, e-mail communications may be made a part of Your permanent medical record.
Termination: Either You or the Practice may terminate this Agreement at any time for any reason, or for no reason, upon 30 days’ written notice to the other. If You terminate the Agreement, Enhancements will no longer be available to You following the end of the notice period. If the Agreement is terminated, the Practice will refund You a prorated amount of the Annual Fee for any months within an applicable year that you did not receive Enhancements, within 30 days of the date after the Agreement termination date; provided, however, that if You have received Your comprehensive annual physical exam at the time of termination, the prorated refund will be reduced by $400. You agree that the Agreement and the terms and conditions defined in the Agreement shall be governed and interpreted under the laws of the State of Michigan, and that any actions or disputes shall be filed and maintained in the appropriate court within Kent County. This Agreement reflects the entire Agreement between You and the Practice as it relates to the Enhancements.
I have received, read, and understand this disclosure.