Consent for Treatment and Patient Services Agreement
WHEREAS, 4 Elements Direct Primary Care, LLC, a limited liability corporation conducting business at 1199 Sullivan Ave, Suite A South Windsor, CT, 06074, and 1111 Cromwell Ave, Suite 304, Rocky Hill, CT 06067, provides Services, as enumerated in Attachment B, incorporated herein by reference.
WHEREAS, Patient, according to the terms of this Agreement, desires to hire 4 Elements Direct Primary Care, LLC, to provide Services.
NOW, THEREFORE, in consideration of the mutual covenants, representations, warranties and promises herein contained, the parties agree as follows:
1 - Definitions:
a. 4E DPC shall mean 4 Elements Direct Primary Care, LLC, together with any and all of its medical practitioners.
b. Patient or “Member” shall mean the individual (or individuals) specifically documented on the appropriate enrollment registration online form. If one or more minors, incapacitated persons or persons subject to a power of attorney are documented on the appropriate enrollment registration online form, “Patient” shall include, jointly and severally, the parent or legal guardian of the Patient.
c. Services. As used in this Agreement, the term Services shall mean a package of services, both medical and non-medical, and certain amenities (collectively “Services”), which are offered by 4E DPC , and set forth in Attachment B and shall exclude any and all other services not specifically enumerated, such as but not limited to specialized services, emergency services, dentistry, prescriptions, lab work, x-rays, ultrasound, MRI and those services 4E DPC is not equipped, licensed or otherwise capable of providing. These Services are also limited to those that the Physician is permitted to perform under the laws of the State of Connecticut and that are consistent with his/her training and experience as an Internist and Pediatrician, as the case may be.
d. Fees. In exchange for the Services described herein, Patient agrees to pay 4E DPC the amounts as set forth in Attachment C, attached. These fees are payable upon execution of this agreement and are in payment for the services provided to Patient by 4E DPC during the term of this Agreement.
2 - Term. The terms of this agreement are as outlined in Attachment A.
3 - Termination. Termination of this agreement is as outlined in Attachment A.
4 - Fees. In consideration for the Services provided, Patient agrees to pay 4E DPC the amount as set forth in Attachment C.
5 - Non-Participation in Insurance. Patient understands and acknowledges that 4E DPC does NOT participate in any health insurance, PPO or HMO plans or panels and does NOT bill Medicare or Medicaid for services for any individual that currently is covered, or in the future becomes covered, by any Medicare or Medicaid programs. 4E DPC does not make any representations or warranties whatsoever that any fees paid under this Agreement are covered by Patient’s health insurance or other third-party payment plans applicable to the Patient. The Patient shall retain full and complete responsibility for any such determination.
6 - Medicare Opt-Out Agreement. The Balanced Budget Act of 1997 allows physicians to “opt out” of Medicare and enter into private contracts with patients who are Medicare beneficiaries. In order to opt out, physicians are required to file an affidavit with each Medicare carrier that has jurisdiction over claims that they have filed (or that would have jurisdiction over claims had the physicians not opted out of Medicare). In essence, the physician must agree not to submit any Medicare claims nor receive any payment from Medicare for items or services provided to any Medicare beneficiary for two years. This Agreement between Patient and 4E DPC is intended to be the contract physicians are required to have with Medicare beneficiaries when physicians opt-out of Medicare. This Agreement is limited to the financial agreement between 4E DPC and Patient and is not intended to obligate either party to a specific course or duration of treatment. Patient understands that 4E DPC and its Physicians have not been excluded from participation under the Medicare program under section 1128, 1156, 1892, or any other sections of the Social Security Act.
As part of this agreement, 4E DPC agrees to the following:
4E DPC agrees to provide Patient such treatment as may be mutually agreed upon and at mutually agreed upon fees.
4E DPC agrees not to submit any claims under the Medicare program for any items or services, even if such items or services are otherwise covered by Medicare
4E DPC agrees not to execute this contract at a time when Patient is facing an emergency or urgent healthcare situation.
4E DPC agrees to provide Patient with a signed copy of this document before items or services are furnished to Medicare beneficiary under its terms. 4E DPC also agrees to retain a copy of this document for the duration of the opt-out period.
4E DPC agrees to submit copies of this contract to the Centers for Medicare and Medicaid Services (CMS) upon the request of CMS.
As part of this agreement, Patient agrees to the following:
Patient agrees to pay for all items or services furnished by 4E DPC and understands that no reimbursement will be provided under the Medicare program for such items or services.
Patient understands that no limits under the Medicare program apply to amounts that may be charged by 4E DPC for such items or services.
Patient agrees not to submit a claim to Medicare and not to ask 4E DPC to submit a claim to Medicare.
Patient understands that Medicare payment will not be made for any items or services furnished by 4E DPC that otherwise would have been covered by Medicare if there were no private contract and a proper Medicare claim had been submitted.
Patient understands that Patient has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that Patient is not compelled to enter into private contracts that apply to other Medicare-covered items and services furnished by other physicians or practitioners who have not opted out of Medicare.
Patient understands that Medigap plans (under section 1882 of the Social Security Act) do not, and other supplemental insurance plans may elect not to, make payments for such items and services not paid for by Medicare.
Patient understands that CMS has the right to obtain copies of this contract upon request.
7 - Insurance or Other Medical Coverage. PATIENT UNDERSTANDS AND ACKNOWLEDGES THAT THIS AGREEMENT IS NOT AN INSURANCE PLAN, NOR A SUBSTITUTE FOR HEALTH INSURANCE OR OTHER HEALTH PLAN COVERAGE (such as membership in an HMO). PATIENT HEREBY REPRESENTS AND WARRANTS THAT 4E DPC HAS ADVISED PATENT TO EITHER OBTAIN OR KEEP IN FULL FORCE SUCH HEALTH INSURANCE POLICY(IES) OR PLANS THAT WILL COVER PATIENT FOR GENERAL HEALTHCARE COSTS.
8 - Communications. Patient understands and acknowledges that communications with 4E DPC using e-mail, facsimile, video chat, instant messaging, and/or cell phone are not guaranteed to be secure or confidential methods of communication. As such, Patient hereby expressly waives 4E DPC’s obligation to guarantee confidentiality with respect to correspondence using such means of communication. Patient understands and acknowledges that all such communications may become a part of his/her medical records. By providing Patient's e-mail address on the appropriate enrollment form, Patient authorizes 4E DPC to communicate with Patient by e-mail regarding Patient's "protected health information" (“PHI”) (as that term is defined in HIPAA). Furthermore, by inserting Patient's email address in the appropriate registration enrollment form, Patient understands and acknowledges that:
a. E-mail is not a secure medium for sending or receiving PHI and there is always a possibility that a third- party may gain access;
b. Although 4E DPC will take reasonable precautions to keep e-mail communications confidential and secure, 4E DPC cannot assure or guarantee the absolute confidentiality of e-mail communications.
c. In the discretion of 4E DPC, e-mail, texting and video chat communications may be made a part of Patient's permanent medical record; and Patient understands and agrees that E-mail/texting is not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information.
d. In the event of an emergency, or a situation in which Patient could reasonably expect to develop into an emergency, Patient must call 911 or the nearest Emergency room, and follow the directions of emergency personnel.
e. If Patient does not receive a response to an e-mail message or text within one (1) business day, Patient agrees to use another means of communication to contact 4E DPC. 4E DPC expressly disclaims any liability associated with any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient as a result of any action, inaction or activity outside the control of 4E DPC or technical issues within 4E DPC control, including but not limited to (i) technical failures attributable to any Internet service provider, (ii) power outages, failure of any electronic messaging software, or failure to properly address e-mail, text and video chat messages, (iii) failure of 4E DPC’s computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of e-mail, text or video chat communications by a third-party; or (v) Patient’s failure to comply with the guidelines regarding use of email communications set forth in this Agreement.
9 - Cross-Coverage. The Physician(s) at 4E DPC may from time to time, due to vacations, sick days, and other similar situations, not be able to provide the Services referred to above. Cross-coverage details are as outlined in Attachment A.
10 - Consent to Photography. Patient authorizes 4E DPC, its employees, agents and attending medical staff to record or document, examinations, medical procedures, surgical procedures and other images of me through the means of photography, videotape, audiotape, motion picture or digital imaging, and any other later developed mediums which result in the permanent documentation of the patient’s image for the following uses and purposes: a) in connection with care and treatment and b) in connection with medical research and education. I agree that my photographs taken by 4E DPC which are not required by law to be retained may be disposed of by 4E DPC provided the manner of disposition shall be permanent destruction. This consent may be revocable by me at any time.
11 – Consent to Telehealth. From time to time, 4E DPC may elect to provide care to the Patient via Telehealth. For the purpose of this Agreement, Telehealth is defined as the electronic communications technologies used by the staff members of 4E DPC, to enable them to obtain information and communicate remotely in order to provide patient care. I understand that the same standard of care applies to medical treatment obtained through telehealth communications as applies to an in-person visit. The information obtained through telehealth communications may be used for diagnosis, treatment, follow-up and/or education, and may include any of the following: a) Patient medical records, b) Medical images, c) Live two-way audio and video and data communications, d) Output data from medical devices and sound and video files, e) Questionnaires, f) email and g) text messaging. The electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Possible benefits of Telehealth include a) Easier access to medical care; b) Convenience; c) More time efficient medical evaluation and management. As with any technology used in medical care, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to: a) Information transmitted may not be sufficient to allow for appropriate medical decision making by the physician; b) Physician may not be able to provide medical treatment for your particular conditions remotely; c) Regulatory and other requirements may limit your physician’s ability to provide certain treatment options, including prescriptions; d) Delays in medical evaluation and treatment could occur due to deficiencies or failures in technology equipment; e) Security protocols could fail, resulting in privacy breaches of personal medical information. Patient acknowledges the risks and benefits and consent to the use of Telehealth.
12 – Use and Disclosure of Protected Health Information. Patient authorizes 4E DPC to use and disclose Patient’s medical information including, if applicable, dental, protected drug and/or alcohol abuse, and confidential HIV-related information (“Protected Health Information”) for treatment, payment and health care operations purposes. Patient’s consent includes the release of such information to process payments, if applicable. The Notice of Privacy Practices explains how 4E DPC may use and disclose Protected Health Information. To better provide care, 4E DPC seeks to coordinate integrated care delivery through the electronic health record, which is paperless. The information may be shared with some other affiliates through a health information exchange. Provider uses a system that allows electronic prescribing of medications. Patient authorizes 4E DPC to request and use prescription medication history from other healthcare providers or third-party pharmacy benefit payers for treatment purposes.
Drug and Alcohol Abuse Information. HHS Confidentiality of Alcohol and Drug Abuse Patient Records regulations protects releasing of information. By signing this Agreement, Patient understands that Patient is allowing disclosure and access to Patient’s health information regarding drug and alcohol abuse through any health information exchanges that 4E DPC is a member of.
HIV-Related Information. HIV-related information is protected under Connecticut law. By signing this Agreement, Patient understands and agrees to allow disclosure of and access to health information regarding HIV-related information through any health information exchanges that 4E DPC is a member of.
Patient understands and agrees that they are allowing disclosure, access to, and exchange of all health information, including information related to alcohol and substance abuse/use, mental or behavioral health, medication prescription history, and HIV/AIDS. Patient understands and agree that Patient is allowing disclosure, access to, and exchange of all my health information that the Provider may have access to through health information exchanges or through access privileges with other health care organizations’ electronic health records. Patient understands if Patient does not want information stored in the electronic health record (which may be shared through health information exchanges), and utilized in Patient’s care, Patient will not be able receive care with 4E DPC, and have the right to opt out of receiving care at any time, which will be considered notice of termination and subject to the Termination clause of this Agreement.
13 – Consent to Newsletter Communications. 4E DPC periodically sends mass communications via newsletter services to keep patients updated with happenings at the practice, new relationships, educational material on health topics, as well as related programs and benefits. 4E DPC tries to minimize mass communication to a reasonable level. By signing this Agreement, Patient explicitly gives permission to receive emails through an email marketing partner software to which 4E DPC has a subscription, at the email address supplied during registration. These email addresses are not sold or shared with any other entity without the Patient’s permission. Patient can withdraw consent to newsletter/marketing communications at any time through written communication at info@4elementsdpc.com requesting to be removed.
14 - Change of Law. If there is a change of any law, regulation or rule, federal, state or local, which affects this Agreement, or the duties or obligations 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 this Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms of this Agreement. If the parties are unable to reach an agreement concerning the modification of this Agreement within forty-five (45) days after the effective date of change, then either party may immediately terminate the Agreement by written notice to the other party.
15 - 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 this 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.
16 - Reimbursement for Services Rendered. If this Agreement is held to be invalid for any reason, and if 4E DPC is therefore required to refund all or any portion of the Fees paid by Patient, Patient agrees to pay 4E DPC an amount equal to the fair market value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid.
17 - Amendment. No amendment of this Agreement shall be binding on a party unless it is made in writing and signed by all of the parties. Notwithstanding the foregoing, 4E DPC may unilaterally amend this Agreement to the extent required by federal, state, or local law or regulation (“Applicable Law”) by sending Patient a thirty (30) day advance written notice of any such change. Any such changes are hereby incorporated by reference into this Agreement without the need for signature by the parties and are effective as of the date established by 4E DPC, except that Patient shall initial any such change upon the request of 4E DPC. Moreover, if Applicable Law requires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been expressly set forth in this Agreement.
18 - Assignment. This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient. 4E DPC, without notice to or consent of Patient, may assign this Agreement to any entity that is controlled, directly or indirectly by, under common control with or affiliated with 4E DPC, or may assign this Agreement to any of its corporate affiliates, to any successor organization, or to any organization acquiring substantially all of its assets. 4E DPC may also subcontract for certain services, including a licensed third party administrator if required by state law. This Agreement shall bind and inure to the benefit of the parties hereto and each of their successors and permitted assigns.
19 - Relationship of Parties. Patient and 4E DPC intend and agree that 4E DPC, in performing its duties hereunder this Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and the United States Department of Labor, and 4E DPC shall have exclusive control of its work and the manner in which it is performed.
20 - Force Majeure. Neither party shall be liable to the other for the failure of delay in the performance of any of his/her/its obligations under this Agreement when such failure or delay is due to fire, flood, strike, riots, wars, embargoes, governmental laws, orders or regulations, storms, pandemics or other similar or different contingencies beyond the reasonable control of the respective parties.
21 - Miscellaneous. This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted. Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text.
22 - Entire Agreement. This Agreement and any attachments hereto contains the entire agreement between the parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement.
23 - Notice. All written notices are deemed served if sent to the address of the party written above or appearing in the appropriate Client Intake Form(s) by first class U.S. mail, and if Patient changes his/her address, Patient shall notify 4E DPC promptly of his/her change of address.
24 - Arbitration. 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 Connecticut law, and not by a lawsuit or resort to court process except as Connecticut law provides for judicial review of arbitration proceedings. Both parties to this contract by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury; and instead are accepting the use of arbitration. It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician and the physician’s partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filling of any action in any court by the physician to collect any fee for the patient shall not waive the right to compel arbitration of any malpractice claim. A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rata share of the expenses and feed of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness feed, or other expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators have the immunity of the judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joiner in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joiner any existing court action against such additional person or entity shall be stayed pending arbitration. All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable Connecticut statue of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition. If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall remain in full force and shall not be affected by the invalidity of any other provision. If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall remain in full force and shall not be affected by the invalidity of any other provision.
25 - Governing Law; Venue; Waiver of Jury Trial. This Agreement shall be construed in accordance with, and governed in all respects by, the substantive laws of the State of Connecticut, without regard to its conflicts of law principles, and applicable federal law. The parties hereby consent to the exclusive jurisdiction and venue in the state courts in Hartford County, Connecticut or federal court for the State of Connecticut, and both parties hereby agree to the personal jurisdiction of said courts. Both parties each irrevocably waive the right to a jury trial in connection with any legal proceeding relating to this Agreement.
I have been given a copy of the Notice of Privacy Practices which I can access here: Notice of Privacy Practices 01/01/2022
IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the Effective Date as of the date of electronic registration by the Patient or Patient’s legal guardian.