Welcome to Big Trees MD!
We offer a wide variety of services that are specifically tailored to your healthcare goals and personal values. This Agreement explains these services and how we will work together.
1. Services.
As used in this Agreement, the term Services means primary care as well as other services within your provider’s scope of practice.
2. Exclusions.
Excluded Services. You may need the care of emergency rooms, outside laboratory testing, pathology studies, prescribed medications, radiologic imaging, specialist consultations or treatment, surgery, urgent care centers, specialty vaccinations, or other healthcare services outside this Agreement’s scope. We highly recommend that you maintain health insurance, which may or may not cover the cost of these services. We will endeavor to place orders for excluded services in a manner that is cost-effective for you.
Controlled Substances. It is not our policy to prescribe chronic controlled substances on your behalf, including commonly abused 8. medications, benzodiazepines, and stimulants. If we do prescribe this class of pharmaceuticals for you, you will be asked to sign and honor our Controlled Substances Agreement.
3. Scheduling. Your advance scheduling notice helps us provide the best possible experience for all of our patients.
Cancellations. If you cannot keep a scheduled appointment, please provide us with a minimum of 24 hours’ notice. You may be charged a missed appointment fee if we do not receive 24 hours’ notice.
Medication Refills. Requests for medication refills are processed during normal business hours, M-F, 8 a.m.- 5 p.m. PST; not in the evening, on weekends, or on holidays. Please be aware that it may take up to 3 business days to have your prescription refilled. Accelerated or after-hours refill requests may incur a fee.
Urgent Care Instructions. The practice operates during regular business hours and is not consistently available for care that requires immediate or urgent attention. Suppose you are experiencing an urgent healthcare need that cannot wait up to 24 hours for a response or the next regular business day, including holidays, whichever is later. In that case, you may be directed to your local urgent care center or Emergency Room, which includes Adventist Health Rapid Care: (209) 736-9130.
Emergency Care Instructions. If you are experiencing a medical or psychiatric emergency, you should immediately call 911 or visit your nearest emergency department. If you should ever need it, the National Suicide Prevention Hotline telephone number is (800) 273-8255.
4. Consent to Treat.
You acknowledge, consent, and hereby authorize Practice, its physicians, and providers to carry out your healthcare treatment. Treatment includes but is not limited to: the administration and performance of all treatments, the administration of any needed anesthetics, the administration and use of prescribed medications, the performance of such procedures as may be deemed necessary or advisable for treatment, including but not limited to diagnostic procedures, the taking and utilization of cultures, and of other medically accepted laboratory tests, all of which in the judgment of the attending physician, provider, or their assigned designees may be considered medically necessary or advisable.
You acknowledge and understand that this consent is given in advance of any specific diagnosis or treatment, that these services are voluntary, and that you have the right to refuse these services.
You understand and intend this consent to be confidential in nature, even after a specific diagnosis has been made and treatment recommended. This consent will remain in full force and effect unless revoked in writing and prior actions will not be affected by your revocation.
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Privacy & Communications.
Your Privacy Rights.
You acknowledge and hereby authorize Practice to use and/or disclose the health information that specifically identifies you, or that can reasonably be used to identify you, to carry out your treatment, payment, and healthcare operations. Practice will adhere to its obligations regarding your privacy rights as identified in Practice’s Notice of Patient Privacy Practices. Your signature on this Agreement attests that you have read, understand, and agree to our Notice of Patient Privacy Practices and have been given a link to the digital copy, which you can print out for your records: https://bit.ly/44UkFeN
5. Methods of Communication.
You acknowledge that Practice communications may include use of cell phones, e-mail, facsimile, instant messaging, and video (collectively, “Communications”). Communications by their nature cannot be guaranteed to be secure or confidential. If you initiate a conversation in which you disclose protected health information on any of these Communication platforms, then you authorize Practice to communicate with you regarding all protected health information in the same format. Communications technology and platforms are wholly outside of our control. Therefore, Practice shall not be liable to you or anyone for any cost, damage, expense, injury, or other loss relating to Communications, malfunctions, or delays in response. Your signature on this Agreement attests that you have read in its entirety, understand, and agree to our Telehealth Informed Consent and that you have been a link to the digital copy, which you can print out for your records: https://bit.ly/3ytog7z
6. Fees.
In exchange for Services, Members agree to pay the Fee for service then in effect. You will be made aware of Fees before Services are performed. Non-Members will agree to pay the Fee for service then in effect and receive a Service quote prior to Services performed.
7. Cessation.
This Agreement will commence on the date it is signed and will continue for 30 days time. Both you and Practice shall have the absolute and unconditional right to terminate this Agreement without cause.
There are certain circumstances in which we may choose to immediately terminate this Agreement including without limitation:
You relocate outside our service area.
Failure to pay Fees when they are due.
Failure to sign our required documentation, as applicable.
Failure to adhere to the recommended treatment plan, especially regarding the use of controlled substances.
You are abusive, disruptive, or present an emotional, physical, or other danger to the well-being of patients, providers, staff, or others.
Practice discontinues operation.
If you need ongoing medical services, you have the option of becoming a Member of Big Trees MD, based on availability. Other options for care would include: Adventist Health (https://doctors.adventisthealth.org/search) and Dignity Health (https://www.dignityhealth.org/ourdoctors).
8. Enforcement. In the event of a determination by any federal, state, or local regulatory or enforcement agency that the arrangement herein contemplated is unlawful or noncompliant with regulatory requirements, then this Agreement shall be automatically reformed to the minimum extent necessary for conformity with law and regulation. If this Agreement cannot be so reformed, then it shall automatically terminate as of the date first triggering the adverse determination. In such a case, this Agreement shall be automatically replaced by Practice’s relevant conforming agreement, if any.
Relationship to Insurance.
Non-Participation in Insurance. You acknowledge that neither Practice nor its providers participate in any public or private Insurance. Neither Practice nor its providers make any representations regarding Insurance reimbursement of Fees paid under this Agreement, and such reimbursement is not anticipated. If you have a health benefit plan or Insurance, we will provide you with documentation so you may submit for your own reimbursement. You are responsible for payment in full at the time Services are rendered.
No Surprises Act. Practice and its providers are not convening providers or co-providers and Practice does not provide facility-based services. As such, it is not anticipated that Services you receive from Practice are subject to Parts D and E of Title XXVII of the Public Health Service Act (also known as the federal No Surprises Act) or state law corollaries. If your care is subject to the No Surprises Act, which may be the case if there was an underlying emergency room visit, hospitalization, or facility-based procedure, then you agree to immediately notify Practice so that we may uphold our legal obligations in this regard.
Non-Participation in Medi-Cal. You specifically acknowledge that Practice and its providers do not participate in Medi-Cal, California’s Medicaid program. This means that Medi-Cal cannot be billed for any Services performed under this Agreement. Further, you agree not to bill Medi-Cal or attempt Medi-Cal reimbursement for any such services.
Non-Participation in Medicare. You specifically acknowledge that pursuant to federal regulations, Medicare beneficiaries are not permitted to enter into this Agreement unless their provider has elected to opt-out of the Medicare program. Maryal Concepcion, M.D. has opted-out of the Medicare program and federal regulations require you to sign our Medicare Beneficiary Private Contract. Medicare cannot be billed for any Services performed under this Agreement. Further, you agree not to bill Medicare or attempt Medicare reimbursement for any such services. By signing this Agreement, you specifically acknowledge and agree that if you are currently a Medicare beneficiary or if you become a Medicare beneficiary in the future, you will immediately notify Practice so that we may uphold our legal obligations.
9. Miscellaneous.
a. Amendment. This Agreement may be amended by Practice from time to time. Your continued engagement of Services will acknowledge your agreement to subsequent amendments.
b. Default. In the event of your default under this Agreement, Practice will be entitled to costs reasonably related to such default.
c. Dispute Resolution. The parties shall endeavor to amicably resolve any disputes arising under this Agreement. If such internal resolution is not effective, each party agrees that final disposition of the dispute shall be resolved by binding arbitration and enforced by any court of competent jurisdiction. The provider of arbitration services shall be determined by Practice. Notwithstanding anything to the contrary, small claims court actions brought by Practice shall be exempt from the requirements of this provision.
It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. The parties specifically waive any and all jurisdictional rights under the laws of any other state. Except for small claims court actions, all disputes arising out of this Agreement shall be settled by binding arbitration. The provider of arbitration services shall be made solely at Practice’s discretion and costs of arbitration shall be borne equally by the parties. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
d. Governing Law. This Agreement shall be subject to and governed by the laws of California without regard to any conflicts of law provisions therein, and the parties specifically waive any and all jurisdictional rights under the laws of any other state. This Agreement will be modified as necessary for compliance with emerging guidance related to the SARS-CoV-2 pandemic, and Practice reserves all rights arising thereunder.
e. Grammar. Unless the context otherwise requires, grammatical references shall be deemed to include masculine, feminine, singular, plural, individuals, and entities, as applicable. The captions and headings for each provision of this Agreement are included for convenience of reference only and shall not be deemed to modify, restrict, or enlarge any of the terms or provisions of this Agreement. Capitalized terms used in this Agreement shall have the definitions provided, including without limitation: (i) “Agreement” means this Patient Agreement as amended from time to time; (ii) “Practice” means the legal entity identified on the first page of this Agreement whether or not made by reference to a fictitious or trade name and may include Practice’s physicians and/or providers, as applicable; (iii) “Fees” means individually and collectively any and all monetary remuneration payable by you to Practice including without limitation the Fees and charges described herein and damages related to your default; and (iv) “Patient Policies & Procedures” means Practice’s written documents and unwritten customs that inform its operations.
f. Integration. This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes any and all other oral or written agreements, representations, negotiations, and understandings.
g. Notices. Any notices or payments required or permitted to be given under this Agreement shall be deemed given when in writing, by electronic transmission, hand delivered, or delivered by traceable carrier with postage prepaid, to the other party at the address set forth herein or as the parties may otherwise designate in writing. All notices shall be deemed delivered as evidenced by verified digital date stamp, on the date of hand delivery, or the date of receipt provided by traceable carrier.
h. Notice to Consumers. Medical doctors are licensed and regulated by the Medical Board of California and are available by telephone at (800) 633-2322 or online at www.mbc.ca.gov.
i. Remedies. All powers, remedies, and rights (“Remedies”) granted to Practice by any particular term of this Agreement are cumulative and in addition to, but not in limitation of, any Remedies that it has under any other term of this Agreement, at common law, in equity, by statute, or otherwise. All such Remedies may be exercised separately or concurrently, in such order and as often as may be deemed desirable by Practice.
j. Severability. In the event that any provision of this Agreement is held to be illegal or unenforceable for any reason, the unenforceability of that provision shall not affect the remainder of this Agreement, which shall remain in full force and effect in accordance with its terms, and any offending provision shall be rectified to the minimum extent necessary for conformity with law unless it cannot be rectified in which case this Agreement shall be interpreted as though the offending provision had not existed.
If this Agreement is held to be invalid or unenforceable for any reason, and if Practice is therefore required to refund all or any portion of the Fees paid by you, you agree to pay Practice an amount equal to the fair market value of the Services actually rendered to you during the period of time for which the refunded Fees were paid commensurate with prevailing rates in the Practice service area.
k. Survival. Any provisions of this Agreement creating obligations extending beyond the term of this Agreement shall survive the expiration or termination of this Agreement, regardless of the reason for such termination.
l. Valid Payment. You agree to keep your account current and pay Fees and charges when they are due. You may be required to keep a valid form of payment on file and if the form of payment provided expires or otherwise becomes invalid, you agree to promptly provide updated payment information. In the event there are costs associated with invalid payment information, including chargebacks and insufficient funds fees, such charges will be applied to your account, and overdue accounts may be subject to interest. By signing this Agreement, you are authorizing Practice to charge the Fees and charges described herein to the form of payment then currently on file and to use this form of payment to pay any and all amounts as those become due. This provision shall survive termination of this Agreement for any reason.
m. Waiver. No waiver of a breach of any provision of this Agreement will be construed to be a waiver of this Agreement, or any other provision herein contained, whether of a similar or different nature, and no delay in acting with regard to a breach shall be construed as a waiver of that breach.