Direct Primary Care Non-Member Patient Agreement
Welcome to a new world of healthcare and wellness, we are glad to have you as a non-member patient of Big Trees MD! As part of being a patient at Big Trees MD, we offer you 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.
a. Virtual Care. Your time is valuable, and so you may choose to receive your care virtually via telephone, text, or video call. We consider Virtual Care a vital part of your patient experience and we are swift to respond to your needs.
b. Ancillary Services. Your care may require ancillary services such as certain laboratory tests not covered as a patient at Big Trees MD. We are happy to discuss whether non-covered services can be billed to your insurance or if there is a cash pay option.
c. Specialty Care Coordination. If your care requires the services of medical specialists outside of Practice, we will make every effort to source the appropriate referral for you and process the referral expediently.
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 that are outside the scope of this Agreement. 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 opioid medications, benzodiazepines, and other stimulants.
Scheduling. Your advance scheduling notice helps us provide the best possible experience for all of our patients.
Cancellations. We request that you provide us with a minimum of 24 hours’ notice if you are unable to attend a scheduled appointment. If we do not receive 24 hours’ notice, you may be charged a missed appointment fee.
Medication Refills. Requests for medication refills are processed during normal business hours; not in the evening, on weekends, or 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 an additional administrative fee.
Urgent Care Instructions. Practice operates during regular business hours and is not available for care that requires immediate or urgent attention. We kindly ask that you limit after-hours, weekend, and holiday communication to urgent situations that cannot wait until the next business day. If 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) then you should immediately call or present at your local urgent care center.
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.
2. Consent to Treat. You acknowledge, consent, and hereby authorize Practice 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 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 continuing in nature, even after a specific diagnosis has been made and treatment recommended. This consent will remain in full force unless revoked in writing and will not affect any actions that were taken prior to receiving your revocation.
3. Privacy & Communications.
Your Privacy Rights. You acknowledge and hereby authorize Practice to use and/or disclose your 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 Patient Notice of Privacy Practices. Your signature on this Agreement attests that you have read, understand, and agree to our Notice of Patient Privacy Practices and that you have been given a copy of the Notice or opted to use a digital copy (available at: https://www.bigtreesmd.com/about-5
4. 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 and our providers 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, understand, and agree to our Informed Consent for Telehealth and that you have been given a copy of such or opted to use a digital copy.
5. Fees. In exchange for Services, Staywell will be billed for the Fees as described in Attachment A.
6. Cessation.
This Agreement will commence on the date it is signed and will continue until it is terminated.
Both you and Practice shall have the absolute and unconditional right to terminate this Agreement without cause.
You may end your agreement upon 30 days written notice. Your notice will be effective on the last day of the month after your notice was received.
If Practice elects to terminate this Agreement, we will provide you with 30 days’ written notice, or other such time necessary to transition your care to another provider.
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 and charges when they are due.
Failure to sign our Controlled Substances Agreement, Informed Consent for Telehealth, or other 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 wellbeing of patients, providers, staff, or others.
Practice discontinues operation.
7. 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.
8. Disclaimer of Non-Insurance. This Agreement does not provide comprehensive health insurance coverage, it is not a health insurance plan, PPO or HMO plan, prepaid health plan, or substitute for healthcare coverage (collectively, “Insurance”). As such, this Agreement is not subject to health insurance protections provided for by state law and does not meet any individual Insurance mandates. This Agreement is solely for the described Services and it does not cover hospital, specialist, or any services not directly provided by Practice.
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.
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 Practice and its providers do not participate in the Medicare program. Maryal Concepcion, M.D. and Jeremiah Fillo, M.D. have opted-out of the Medicare program and federal regulations require you to sign our Medicare Beneficiary Private Contract for services covered by Medicare. Failure to sign our Medicare Beneficiary Private Contract will result in being automatically terminated and any unearned Fee will be prorated and refunded to you, as required. 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.
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 contained and the parties specifically waive any and all jurisdictional rights under the laws of any other state.
e. Grammar and Headings. Unless the context otherwise requires, the singular shall include the plural and the plural may refer only to the singular. The use of any gender shall be applicable to all genders. Capitalized terms used in this Agreement shall have the definitions provided. 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.
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.
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.
Notice to Consumers. Medical doctors are licensed and regulated by the Medical Board of California available by telephone at (800) 633-2322 or online at www.mbc.ca.gov.
g. 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.
h. 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.
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.
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.
Your signature below means that you have read, understand, and agree to all of the terms contained in this Agreement, the Notice of Patient Privacy Practices, and the Telehealth Informed Consent. If you are enrolling patients other than yourself, your signature means that you have the authority to act on their behalf and you are financially responsible for Services they receive under this Agreement. “
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Attachment A
Fees. In exchange for Services, Staywell will be billed the following Fees. Fees may be a permissible expense under a qualified flexible spending account or healthcare reimbursement arrangement. Consult with your accountant if you have questions.
STAYWELL RESPIRATORY ALLERGY CARE PLAN: $2500/year
Annual Quest Respiratory Allergy Panel
Included
Respiratory Allergy Drop Prescription
Included
Pre-Seasonal Allergy Drop Prescription (if needed)
Included
Quarterly Virtual Visits with your Doctor
Included
Virtual Allergy Questionnaire Symptom Update
Included
Itemized Charges. The fees for Itemized Charges change in response to our costs and we endeavor to make these services as affordable as possible. You will be made aware of the fees for Itemized Charges in advance of the services being performed. Payment for Itemized Charges is due at the time services are rendered.
Valid Payment. You are 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. Insufficient funds or chargebacks may result in a charge on your account, and overdue accounts may be subject to interest. You agree to keep your account current and pay Fees and charges when they are due. One example would be purchasing of a prescription at wholesale pricing through Big Trees MD and the bill can be submitted to Staywell for reimbursement.
Employer Sponsored Plan. If your plan is being paid for by your employer, the applicable terms of the Employer Agreement are incorporated by reference as though fully set forth herein. If your employer-sponsored plan ceases, the Fees then in effect shall apply to your plan.
Obligations contained in this Attachment A shall survive termination of this Agreement for any reason.