Advanced Wellness Program Agreement

Advanced Wellness Program Agreement

Fill out the form below to join Dr. Grover's Concierge Advanced Wellness Program!
Overview of Benefits
ASSESSMENTS INCLUDE:
- Annual wellness exam
- Evaluation of expanded/comprehensive blood work
- Genetic testing and counseling (if indicated or desired)
- Body fat analysis
- Interpretation and counseling of advanced cardiac screenings such as heart scans or carotid ultrasounds
GAME PLAN RECOMMENDATIONS:
• Goals are given to members to help them achieve an optimal state of Mind, Body, Lifestyle in a functional, integrative approach.
• Quarterly or semi-annual follow-up with counseling to help you achieve your goals. Please remember to schedule time with Dr. Grover every 3-4 months. You may schedule your appointments online or call our office manager for scheduling assistance. Please let us know if you’d like to have appointments made as placeholders, then you can always adjust date if needed.
• Preventative Health care recommendations-Cardiovascular, Cancer screening etc.
• Hormone balancing recommendations and adjustments if needed.
• IV therapy and peptide recommendations
• Skin care evaluation and recommendations
• Regenerative medicine recommendations such as Platelet rich plasma, stem cell therapies, exosomes, nutrition, etc.
PREVENTION RECOMMENDATIONS:
Given at annual comprehensive wellness exam for preventative cardiovascular and cancer screening and with follow-up visits.
ANTI-AGING/BIO-IDENTICAL HORMONE THERAPY EVALUATION &TREATMENT BENEFITS:
If desired by patient Dr. Grover will order, review and make recommendations for optimizing sex hormones, thyroid, adrenal and growth hormone as indicated.
INTEGRATIVE/FUNCTIONAL MEDICINE BENEFITS:
Counseling on complementary/alternative medicine treatments which may be beneficial such as functional medicine, acupuncture, herbal therapy, nutritional therapy.
ROUTINE VISITS:
Routine visits for management of acute or chronic conditions are included. A total number of visits per year is limited to 10/year, with additional charge if extra visits are needed.
WELLNESS COACHING:
Quarterly visits or phone consultations/skype are available for consultations to review wellness goals, progress and adjustments.
NUTRITIONAL COACHING:
Annual evaluation and coaching with quarterly follow-up as needed. Interpretation of nutritional labs if needed.
LAB TESTING:
Lab tests will be ordered and interpreted by Dr. Grover, but it is the responsibility of the patient to submit lab test costs to insurance, health savings, flex account, or to cover out of pocket expenses if needed. Patients may elect to not do particular blood tests or screens if it is too costly. Dr. Grover is not responsible for lab costs not covered by your plan. He will do his best to add ICD 10 codes, but coverage changes constantly with plans.
OTHER BENEFITS:
·      Physician access via cell phone for urgencies, and email for medical advice.

·      Accommodations whenever possible for same day or next business day appointments for urgent medical reasons.

·      Unhurried thirty minute or longer appointments.

·      Zoom/phone visits when appropriate.

·      Private waiting area with access to internet and refreshments.
FINANCIAL BENEFITS:
- 10% off photofacials, Vivace, Intense Pulsed light, and Fractional Laser treatments, Platelet rich plasma and fillers. Botox at $12/unit.
- 10% DISCOUNT ON ALL SUPPLEMENTS
- TWO FREE Pulse Electromagnetic Frequency Therapy Sessions (PEMF) annually
- 15% off packages of 6+ sessions
- Additional family, spouse, sibling or significant other may receive a 10% discount on their membership fee

MEMBERSHIP FEES & PAYMENT OPTIONS
Members shall pay an annual membership fee to Fred Grover Jr. M.D. in the amount specified below. The annual membership fee covers a period of one calendar year starting on the effective date. Members will have the option to make a one-time payment or quarterly payments by credit card if desired.

Dr. Grover will notify you of the renewal fee at least thirty days prior to the one-year anniversary of the effective date only if it is different from the current membership fee.

Cancellation by member. If member decides to cancel, a refund is not provided. We will of course discontinue current automatic charges moving forward. Similar to a health club, one should be proactive and come in. We recommend making office or virtual appointments at least every 3 months to take advantage of the program. Health clubs don’t refund your money if you don’t come in, and we don’t either.

Unless either party notifies the other party at least thirty days prior to the expiration of the applicable term of non-renewal of this agreement or unless this agreement is earlier terminated as set forth in paragraph four below, this agreement shall automatically renew for successive one-year periods and the payment schedule will remain as set forth below. Failure to pay the annual fee within 45 days of renewal date shall result in automatic termination of this agreement and your membership in the program. Please call us if you need to update a credit card or if there is a concern with our billing program charges. Thank you.
PLEASE CHECK DESIRED FEE SCHEDULE*

ANNUAL payment of $4000 ($4500 annually if 70 or older)QUARTERLY auto-charged payments of $1000 every 3 months. ($1125/quarter if 70 or older)
PLEASE CHECK DESIRED PAYMENT METHOD*

I have enclosed a check for the total membership fee made payable to Fred Grover Jr. M.D. for $4000. ($4500 if 70 or older)I authorize Revolutionary MD to charge my credit card on file quarterly payments of $1000 ($1125/quarter if 70 or older)

CREDIT CARD INFORMATION

This information is added to your patient portal and will be used according to your previously indicated auto-fee schedule.
PLEASE FILL OUT BELOW INFORMATION ONLY IF REVOLUTIONARY MD OFFICE STAFF DOES NOT HAVE YOUR CREDIT CARD INFORMATION ALREADY ON FILE.

If you feel more comfortable calling Revolutionary MD Office with this information instead, please do so.
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Card CVV
Billing Zip Code
Signature

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TERMINATION
By checking "I agree", you understand that Dr. Grover may terminate this agreement by giving thirty days prior written notice to the other, at any time and for any reason. He will not be able to continue refills of medications beyond a 3-month grace period should this agreement be terminated. Please be advised no reimbursements or refunds will be issued.*

I agreeI do not agree
EMAIL OR ZOOM COMMUNICATIONS PRIVACY
By checking "I agree", you are aware that by wishing to communicate via email, phone, or Zoom with Dr. Grover, your personal health information may not be protected through a secure medium. Although Dr. Grover will take steps to keep your communications with his practice confidential and secure, the confidentiality of email communications cannot be assured or guaranteed.*

I agreeI do not agree
MEMBERSHIP FEE
By checking "I agree", I understand that the annual membership fee covers only the defined services described above. The defined services are not covered in whole or in part by private health insurance or third-party payment programs providing health related benefits (including Medicare or any other government payer). Member acknowledges and agrees that the membership fee does not constitute payment in whole or in part for any medical, clinical, diagnostic, or therapeutic services or for any items that are covered in whole or in part by any payers providing benefits to member. This membership is not a health insurance plan. Member represents and agrees that the services and the membership fee are not covered or reimbursable by any payers.*

I agreeI do not agree
MEMBERSHIP RESPONSIBILITIES
The program is not intended as a replacement for any health insurance or similar benefits program maintained by any payer program and does not affect any applicable co-payments, co-insurance, or deductible there under (which you must continue to pay under the terms of such insurance programs), this agreement is not a service contract and not a contract of insurance. We do not submit claims to insurance. We are opted out of Medicare and all plans, but Dr. G can write orders, referrals and prescriptions for plans to cover in most cases.

Notices: Any communication required or permitted to be sent under this agreement shall be in writing sent via fax, mail or email to the addresses set forth in this agreement. Any changes in address shall be communicated in accordance with the section.

Assignment: You may not assign this agreement or any rights and benefits provided in this agreement, without our prior written consent. Any attempt by you to assign this agreement without such consent shall be null, void, and of no legal effect. We may assign this agreement to any person or entity that agrees to abide by the terms of this agreement.

Governing law: This agreement shall be governed by and construed in accordance with the laws of the state of Colorado, not withstanding the principals of conflicts of law.

Entire agreement: Each of the undersigned agrees to the terms of this agreement, all of which are expressed herein. There are no promises or representation except as set forth herein. This agreement may not be modified or amending without the written consent of Fred Grover Jr. M.D.

Effective date: This agreement shall be effective on the date signed by office staff below; provided that the payments have been received. Fred Grover Jr. M.D is not obligated to accept this agreement or payment, and may in its sole discretion; elect not to do so based on the limitations on the number of members and other restrictions.
By signing below, you are consenting to any and all principles, agreements, and responsibilities stated above.*

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Advanced Wellness Program Agreement

Overview of Benefits

ASSESSMENTS INCLUDE:

GAME PLAN RECOMMENDATIONS:

PREVENTION RECOMMENDATIONS:

ANTI-AGING/BIO-IDENTICAL HORMONE THERAPY EVALUATION &TREATMENT BENEFITS:

INTEGRATIVE/FUNCTIONAL MEDICINE BENEFITS:

ROUTINE VISITS:

WELLNESS COACHING:

NUTRITIONAL COACHING:

LAB TESTING:

OTHER BENEFITS:

FINANCIAL BENEFITS:

MEMBERSHIP FEES & PAYMENT OPTIONS

CREDIT CARD INFORMATION

TERMINATION

EMAIL OR ZOOM COMMUNICATIONS PRIVACY

MEMBERSHIP FEE

MEMBERSHIP RESPONSIBILITIES