BLOOM PEDIATRICS AND LACTATION, LLC

KANSAS STATE NOTICE: THIS MEDICAL RETAINER AGREEMENT DOES NOT CONSTITUTE INSURANCE, IS NOT A MEDICAL PLAN THAT PROVIDES HEALTH INSURANCE COVERAGE FOR PURPOSES OF THE FEDERAL PATIENT PROTECTION AND AFFORDABLE CARE ACT AND COVERS ONLY LIMITED, ROUTINE HEALTH CARE SERVICES AS DESIGNATED IN THIS AGREEMENT.

This Patient Agreement (Agreement) is entered into between Bloom Pediatrics and Lactation, LLC (Practice, Us or We), and

The Practice, physically located at 2870 West 47th Avenue Kansas City, Kansas 66103, provides pediatric services to its patient/members in a direct pay primary care practice model (DPC). In exchange for certain periodic fees (or Membership Fees), the Practice agrees to provide the Patient with the Services described in this Agreement under the terms and conditions contained within..

1. Patient. “Patient” or “Member” means the persons party to this Agreement, for whom the Physician shall provide care, and whose names appear in Appendix B, which is attached to this Agreement and incorporated by reference.

2. You, Your. Means the Parent or legal guardians of the minor Patients named within, who is a signatory to, and bound by, this Agreement.

3. Services. In this Agreement, “Services” means the collection of medical and non-medical services provided by the Practice to the Patient in exchange for the Membership Fees and which are identified in Appendix A (attached and made a part of this Agreement).

4. Term. This Agreement will last for one year, starting the date on which it is fully executed by the parties.

5. Renewal. The Agreement will automatically renew each year on the anniversary date of the Agreement unless either party terminates the Agreement by giving 30 days written notice of intent to terminate.

6. Termination. Either party can end this Agreement at any time by giving 30 days written notice to the other, of intent to terminate.

7. Termination for cause. This Agreement may be terminated immediately in the event of violation of the physician-patient relationship or a breach of the terms of the Agreement.

8. Early termination

     (a) If the Practice terminates this Agreement for any reason, We will refund you the unused portion of your Membership Fee on a per diem basis.

     (b) If the Patient cancels this Agreement before its termination date, We will review and settle your account as follows:

           (i) We will refund You the unused portion of your Membership Fee on a per diem basis; or

           (ii) If the Fair Market Value of the Services you received during the term of the Agreement before you canceled is more than the total amount that You paid in Membership Fees during the same period, You shall reimburse the Practice in the amount of the difference. The Parties agree that the Fair Market Value of Services is equal to the Practice’s usual and customary fee-for service charges would be. A copy of these fees is available on request.

9. Payment Amount and Methods. In exchange for the Services, You agree to pay a monthly Membership Fee in the amount described in Appendix C (attached and incorporated into this Agreement by reference).

     (a) Upon execution of this Agreement, Patient shall pay a one-time, non refundable supply fee of their choosing in the amount identified in Appendix C, as well as the regular monthly Membership Fee, which shall start the first day of the doctor-patient agreement. Thereafter, the Membership Fee shall be due on the day of the month marking the start of the care agreement.

     (b) The Parties agree that the required method of payment shall be electronic payment through ACH (preferred) or via debit or credit card.

     (c) You are responsible for the costs associated with any laboratory testing, specimen analysis, product or procedure which is not personally provided by the Practice and listed in Appendix A.. Staff shall inform You in advance if such additional costs may apply and You shall have the following options:

          (i)You shall be advised of the cost and availability of the above products/ procedures at highly discounted, cash-pay rates from select vendors. If available, and You select this option, payment is due at the time of service;

          (ii) You may also purchase necessary products/procedures at any provider or facility of Your choice. You are responsible for all costs, however, You may request that such provider submit their charges to Your health plan (if any) for possible reimbursement.

10. Non-Participation in Insurance. We do not participate with an third party payors, including health insurance, HMO, or government-sponsored health plans. Further, You have been advised that the law prohibits any party from billing or attempting to obtain reimbursement from any third party payor for any Services which are included under this Agreement.

11. Medicare. The Physician and the Practice have opted out of Medicare. As a result, Medicare cannot be billed for any services We personally provide to the Patient. You agree not to bill Medicare or attempt to obtain Medicare reimbursement for any such services. If the Patient is eligible or becomes eligible for Medicare during the term of this Agreement, You shall either: (a) agree to execute a Medicare Opt-Out and Waiver Agreement which We shall provide you; or (b) This Agreement shall be terminated.

12. This Agreement Is Not Health Insurance. This Agreement is not an insurance plan or a substitute for health insurance. You understand that this Agreement is not a replacement for any existing health insurance or health plan coverage that You may carry. This Agreement does not include hospital services, or any services not personally provided by the Practice or its staff. You acknowledge that We have advised You to obtain or continue in full force, health insurance that will cover Patient for healthcare services not personally delivered by the Practice, including but not limited to specialist care, hospitalizations, and catastrophic medical events.

13. Communications. The Practice endeavors to provide You with the convenience of a wide variety of electronic communication options. We are careful to comply with confidentiality requirements and make every attempt to protect patient privacy. However, communications by email, facsimile, video chat, cell phone, texting, and other electronic means can never be guaranteed to be absolutely secure or confidential methods of communications. By placing your initials at the end of this Clause, You understand and acknowledge this. By initialing this clause or agreeing to participate in the above means of communication, you expressly waive any guarantee of absolute confidentiality with respect to their use. You further understand that participation in any of the above means of communication is not a condition of membership in this Practice and that you have the option to decline any means of communication. By typing your initial, the Parties agree this has the same effect as a handwritten initial and is legally binding.

14. Email and Text Usage. By providing an email address where requested in Appendix B, You authorize the Practice and its staff to communicate with You by email regarding the Patient’s “protected health information” (PHI).(1) Likewise, in providing a cell phone number where indicated in Appendix B and checking the “YES” box on the corresponding consent question, You agree to participate in text message communication containing PHI through the cell number provided. You further acknowledge that:

     (a) Email and text message are not necessarily secure methods of sending or receiving PHI, and there is always a possibility that a third party may gain access;

     (b) Email and text messaging are not appropriate means of communication in an emergency, for dealing with time-sensitive issues, or for disclosing sensitive information. In an emergency or a situation which could reasonably be expected to develop into an emergency, You understand and agree to call 911 or go to the nearest emergency room, and follow the directions of emergency personnel.

15. Dispute Resolution. Each party agrees to refrain from making any inaccurate or untrue disparaging statements, oral, written, or electronic, about the other. We strive to deliver only the best of personalized patient care to every Member, but occasionally misunderstandings arise. We welcome sincere and open dialogue with our Members, especially if we fail to meet expectations, and We are committed to resolving all of Your concerns.

     Therefore, if You are ever dissatisfied with, or have concerns about, any staff member, service, treatment, or experience arising from Your child’s membership in this Practice, both You and the Practice agree to refrain from making, posting or causing to be posted on the internet or any social media, any untrue, inaccurate, disparaging comments about the other. Rather, the Parties agree to engage in the following process:

          a) You shall first discuss any complaints concerns or issues with Dr. Hughes;

          b) Dr. Hughes shall respond to each issue and complaint;

          c) If, after such response, You remain dissatisfied, the Parties shall enter into discussion and attempt to reach a mutually acceptable solution.

(1) As that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulations.

16. Physician Absence. From time to time, due to vacations, illness, or personal emergency, the Physician may be temporarily unavailable. The Practice will always attempt to notify You of any planned Physician absence, but that may not always be possible. In the event of an unplanned event, patients with scheduled, non-urgent appointments shall be notified and rescheduled at the Patient’s convenience. Patients have the right and the option to seek treatment at an Urgent Care or any other outside provider. However, charges for outside providers are not included in this Agreement and shall be the Patient’s responsibility. And although charges may be submitted to Your insurance plan (if applicable) for reimbursement consideration; You remain responsible for understanding Your health insurance payment policies and We cannot guarantee reimbursement.

17. Fee and Service Offerings Adjustments. In the event that the Practice finds it necessary to increase or adjust its Service offerings or monthly fees before the termination of the Agreement, We shall give You 30 days written notice of any adjustment. If You do not consent to the modification, You may terminate the Agreement in writing prior to the next scheduled monthly payment.

18. Change of Law. If there is a change of any relevant law, regulation or rule, federal, state, or local, which affects the terms of this Agreement, the parties agree to amend this Agreement only to the extent necessary to comply with the law.

19. Severability. If any part of this Agreement is considered legally invalid or unenforceable by a court of competent jurisdiction, that part will be amended to the extent necessary to be enforceable, and the remainder of the Agreement will stay in force as originally written.

20. Amendment. Accept as provided within, No amendment of this Agreement shall be binding on a party unless it is in writing and signed by all the parties.

21. Assignment. This Agreement, and any rights the parties have under it, may not be assigned or transferred.

22. Legal Significance. You acknowledge that this Agreement is a legal document and gives the parties certain rights and responsibilities. You further acknowledge that You have had reasonable time to seek legal advice about the Agreement and have either chosen not to do so, or have done so, and are satisfied with the terms and conditions of the Agreement.

23. Miscellaneous. This Agreement shall be interpreted without regard to rules requiring that it be construed against the drafter. The captions in this Agreement are only for the sake of convenience and have no legal meaning.

24. Entire Agreement. This Agreement contains the entire Agreement between the parties and replaces any earlier understandings and agreements, whether written or oral.

25. No Waiver. The parties agree that they may choose not to enforce any of the other party’s requirements or duties under this Agreement. Doing so will not constitute a waiver of that duty or responsibility. The party will have the right to enforce such terms again at any time.

26. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Kansas. All disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for the Practice in Kansas City, Kansas.

27. Notice. Written notice required under paragraph 17 above, may be accomplished electronically by email sent to the latest address provided by the party to be noticed, or by first class US mail. All other required notices must be sent by first class U.S. mail: to the Practice, at the address written above and to Patient or representative, at the address appearing in Appendix B

28. Not primary care. Patient/You agree and recognize that Bloom Everywhere is not primary care, nor will they act as a primary care provider. You agree to have a Primary Care Provider (PCP) for the Patient to complete all well-checks, immunizations, documentations, and in-person visits as needed.

The Parties may have signed duplicate counterparts of this Agreement on the date first written above.

The Parties agree that by using the mouse to sign below, this constitutes an electronic signature. The Parties agree that such electronic signature has the same effect as a handwritten signature and is legally binding.

1. Medical Services.* Medical Services under this Agreement are those Services which are consistent with Physician’s training and experience, and as deemed medically appropriate to be completed virtually in the sole discretion of the Physician, to include the following:

• Lactation Consultation and Support
• Some acute/sick visits
  • If Nonagon is purchased, this will include ear infections, lung/heart evaluations, throat examination, and blood oxygen evaluation
• Parent questions for common pediatric conditions
• Chronic Condition Management, such as asthma and diabetes
• If testing kit is purchased:
  
  • Dipstick Urinalysis
  • Rapid Strep Test
  • Rapid flu test
  • Rapid COVID test
  • Rapid RSV test
• Ordering and interpreting labs
• Ordering and interpreting imaging

*Note: Fees associated with any drugs, laboratory testing, imaging, and specimen analysis associated with the above which cannot be performed onsite, or must be provided through a third party vendor are not included in the monthly fee, but shall the responsibility of the Parent/guardian. Labs and testing that cannot be performed virtually will be offered at a discounted rate through select vendors. Payment is due at the time of service.

*Note: If Patient cancels contract prior to 3 months continuous medical care, Patient will be charged the Per Visit Fee ($200 per child per visit) in addition to the monthly fee. Full Fee schedule is available on request.

*Note: Agreement does NOT include completing school forms, school physicals, or other documentations requiring in-person visits or well checks. We do not offer mental health services such as anxiety, depression, ADHD, autism, or OCD medical management.

2. Non-Medical, Personalized Services. The Practice shall also provide Patient with the following non-medical services, which are complementary to our members in the course of care:

• After Hours Access. The Practice shall endeavor to provide direct telephone access to the Physician seven days per week for guidance for urgent concerns that arise unexpectedly after regular business hours.

• Email Access. You shall be given the Physician’s email address to which non-urgent communications can be addressed. You understand and agree that email and the internet should never be used to access medical care in the event of an emergency, or any situation that could reasonably develop into an emergency.

• Timely Appointments. All reasonable effort shall be made to assure that the Patient is seen promptly at the scheduled time. If the Physician foresees more than a minimal delay, You shall be contacted and advised of the projected delay time and shall have the option of being seen at the later time or rescheduling at a time convenient for You.

• Same Day/Next Day Appointments. Every reasonable effort shall be made to accommodate same or next business day appointments when necessary and requested.

• Primary care provider Communication. The Physician shall provide all Patient medical documentation to family upon request, to share with their Primary Care Provider to ensure approrpiate continuity of care. Reminder that a Primary Care Provider is required for all well visits, school forms, and other required in-person visits.

THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING PATIENT(S). THE PARENT OR GUARDIAN, BY SIGNING THIS APPENDIX B, CERTIFIES THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT.

CHILD/CHILDREN TO WHOM THIS AGREEMENT APPLIES:

PARENT OR GUARDIAN

(Provide email address only if you agree to Email communication)

Check YES where indicated only if you agree to text message communication. Your signature indicates acceptance of the terms of the Patient Agreement

 MONTHLY MEMBERSHIP FEE

THERE IS A 3% ADDITIONAL FEE FOR ALL THOSE WHO PAY WITH A CARD. TO AVOID THE FEE, PLEASE ENROLL USING ACH/AUTOMATIC BANK DRAFT

Re-Enrollment Fee: If, after allowing membership to lapse or be terminated, Patient desires to rejoin the Practice, they shall be accepted on a space-available basis, subject to a $300 re-enrollment fee

You will be charged for your non-refundable supply purchase upon payment of invoice. Monthly membership fee will start after whichever of these events occurs first: upon shipment of supplies, 2 weeks after enrollment, or first visit (text or virtual).

We will contact you about shipment of equipment if ordered and send you tracking information. 

You will receive an email for the invoice of your total above from Hint soon.

You will receive a text to download the OhMD app and connect to Bloom Everywhere. This will be our texting platform. 

Lastly, if you purchased Nonagon, I will send you my physician code upon receipt.