• New Patient Paperwork - 2024

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    • Note: We are currently in network with the following Insurances:

      • Aetna
      • Anthem 
      • United
      • Medicare
      • Medicaid

      We are not in network with Cigna or Humana

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    • Program Selection 

    • Program Descriptions

      Traditional Primary Care Program

      • Our standard program in the practice.  This is the baseline level of care that we offer to our patients.  Patients can establish care with us and drop in at any time for routine care.  There are no ongoing costs or fees associated with this.  We accept certain insurance carriers as well as self-pay patients into this program.
      • All patients are by default enrolled in our Traditional Primary Care Program
      • No Restrictions to this program

       

      Optional: Membership Programs

      The following programs may be selected after joining our practice and having your establish care appointment.  If you would like more information on them please discuss them with your provider at your appointment

      Direct Primary Care Membership Program (OPTIONAL UPGRADE)

      • This program was designed to provide concierge-level care for those without insurance or who do not wish to use insurance.  For a flat monthly fee, a majority of the care that patients receive is included.  Patients in this program have no-cost visits, access to virtual care / virtual visits, house calls, and more.  Procedures, labs, and services are offered at substantially discounted cash pay rates compared to traditional pricing.  Members get priority scheduling and can typically be seen the same day or the next day. 
      • Non-included services in this program may be offered at cash discounts or can be billed to insurance as per patient preference
      • Restrictions: Cannot have Medicare or Medicaid

      Medicare Concierge Program (OPTIONAL UPGRADE)

      • This program was designed for Medicare Patients and allows them to experience our high-quality membership programs.  They receive similar perks to our Direct Primary Care Membership Program such as priority scheduling, virtual visits, house calls, etc.  We will bill Medicare for any services rendered

       

      Note:

      Membership is opt-in and is only offered after establishing care with our practice.  Patients may opt-in at any time to receive additional perks and benefits.   

    • WARNING:

      Medicare patients cannot join our Direct Primary Care Membership Program

    • WARNING:

      Medicaid patients may not join either of our membership programs

    • Standard Agreements 

    • Fee for Service Patient Agreement - Traditional Primary Care Program

      Welcome to a new world of healthcare and wellness, we are glad to have you at Starlight Health.  As part of your care, 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.  As used in this Agreement, the term Services means primary care as well as other services within your provider’s scope of practice.  In exchange for Services, you agree to pay the Fee for service then in effect.  You will be made aware of Fees before Services are performed.
      2. Relationship to Insurance.  It is important for us to know what kind of benefits you have so we can properly bill you for your share of cost.  If your benefits change at any time, you agree to let us know right away so we can uphold our legal obligations in this regard.In-Network.  For Insurances in which Practice participates, we will submit billings for reimbursement of charges for health Services that are a covered benefit.
        1. Out-of-Network.  For Insurances in which Practice does NOT participate, upon request we will provide you with documentation so you may submit for your own reimbursement.  You are responsible for payment in full at the time
        2. Services are rendered.
        3. Medicare.  We will submit billings for reimbursement of charges for designated health services that are a Medicare covered benefit.  However, Medicare Advantage (Part C), Medi-Gap (Part F), and other Insurance plans may not reimburse for our charges.  It is important for us to know what kind of benefits you have so we can properly bill you for your share of cost.  If your benefits change at any time, you agree to let us know right away so we can uphold our legal obligations in this regard.
        4. Medicaid.  You specifically acknowledge that you will inform practice of your Medicaid status and will notify us should it ever change.
      3. 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.
      4. Exclusions.
        1. 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.
        2. Controlled Substances.  It is not our policy to prescribe chronic controlled substances on your behalf, including commonly abused opioid 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.
      5. Scheduling.  Your advance scheduling notice helps us provide the best possible experience for all of our patients.
        1. 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.
        2. Medication Refills.  Requests for medication refills are at the discretion of your assigned provider and will be 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. 
        3. Urgent Care Instructions.  Practice operates during regular business hours and is not consistently available for care that requires immediate or urgent attention.  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 may be directed to go to your local urgent care center.
        4. 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 988.
      6. 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.
        1. 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 and effect unless revoked in writing and prior actions will not be affected by your revocation.
      7. Privacy & Communications. 
        1. 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 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 that you have been given a copy of such or opted to use a digital copy.
        2. Methods of Communication.  You acknowledge that Practice communications may include use of cell phones, e-mail, facsimile, instant/MSM/text messaging, patient portal messages, 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, understand, and agree to our Telehealth Informed Consent and that you have been given a copy of such or opted to use a digital copy.
      8. Cessation.
        1. 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.
        2. If Practice elects to terminate this Agreement, we will provide you with 30 days’ written notice, or any such other time necessary to transition your care to another provider.
        3. There are certain circumstances in which we may choose to immediately terminate this Agreement including without limitation:
          1. You relocate outside our service area.
          2. Failure to pay Fees when they are due.
          3. Failure to sign our Telehealth Informed Consent, Controlled Substances Agreement, or other required documentation, as applicable.
          4. Failure to adhere to the recommended treatment plan, especially regarding the use of controlled substances.
          5. You are abusive, disruptive, or present an emotional, physical, or other danger to the wellbeing of patients, providers, staff, or others.
          6. Practice discontinues operation.
        4. 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.
      9. Miscellaneous.
        1. Amendment.  This Agreement may be amended by Practice from time to time.  Your continued engagement of Services will acknowledge your agreement to subsequent amendments.
        2. Default.  In the event of your default under this Agreement, Practice will be entitled to costs reasonably related to such default.
        3. 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 and county court actions brought by Practice shall be exempt from the requirements of this provision.
          1. It is understood that any claim of medical malpractice, including any claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered or omitted, will be determined by submission to binding arbitration in accordance with the provisions of part 2 of article 22 of title 13 of the Colorado Revised Statutes, and not by a lawsuit or resort to court process except as Colorado law provides for judicial review of arbitration proceedings.  The patient has the right to seek legal counsel concerning this Agreement, and has the right to rescind this Agreement by written notice to the physician within 90 days after the Agreement has been signed and executed by both parties unless said Agreement was signed in contemplation of the patient being hospitalized, in which case the Agreement may be rescinded by written notice to the physician within 90 days after release or discharge from the hospital or other health care institution.  Both parties to this Agreement, by entering into it, have agreed to the use of binding arbitration in lieu of having any such dispute decided in a court of law before a jury.
        4. Governing Law.  This Agreement shall be subject to and governed by the laws of Colorado 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.  This Agreement will be modified as necessary for compliance with emerging guidance related to public health matters and Practice reserves all rights arising thereunder.
        5. 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 Starlight 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 fictious or trade name and may include Practice’s physicians and/or providers, as applicable; (iii) “you” and “your” reference the individual receiving Services under this Agreement, and/or the legally responsible individual (as applicable); (iv) “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; (v) “Insurance” means health insurance plans, PPO or HMO plans, prepaid health plans, Medicaid, Medicare, other state and/or federal public healthcare programs, and substitute healthcare coverage (as applicable); (v) “Patient Policies & Procedures” means Practice’s written documents and unwritten customs that inform its operations; and other capitalized terms have the definitions ascribed to them by law and regulation.
        6. Integration.  This Agreement all oral or written agreements, representations, negotiations, and understandings except for our membership agreements in which case this agreement is superceeded by either our Direct Primary Care Membership Agreement or Concierge Membership Agreements if the patient has opted-in
        7. 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.
        8. 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, by statute, at common law, in equity, or otherwise.  All such Remedies may be exercised separately or concurrently, in such order and as often as may be deemed desirable by Practice.
        9. 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.
          1. 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.
        10. Survival.  Any provisions creating obligations extending beyond the term of this Agreement shall survive its expiration or termination, regardless of the reason, whether or not the right of survival was explicitly reserved.
        11. 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 and bill for the Fees and charges described herein (including without limitation the share of cost due under your health plan, as applicable) 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.
        12. 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.

       

       

    • NOTICE OF PRIVACY PRACTICES
      Starlight Health, L.L.C.


      PLEASE REVIEW THIS NOTICE CAREFULLY
      IF YOU ARE A MEMBER AND HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT OUR OFFICE THROUGH THE SECURE PATIENT PORTAL
      As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

      THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GAIN ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.

       


      OUR RESPONSIBILITY 
      Starlight Health is committed to protecting the privacy of your medical information. Your care/treatment is recorded in a medical record that is considered protected health information (“PHI”). To best meet your medical needs, we share your PHI with the providers and facilities involved in your care. We share your information only to the extent necessary to collect payment for services we provide and to conduct our business operations. We train our employees, associates and providers to be sensitive to the privacy and confidentiality of your PHI. Except as outlined below, we will not use or disclose your PHI for any other purpose unless you have signed a Medical Record Release Authorization form.

      USES AND DISCLOSURE OF YOUR PHI
      We may use and share your PHI in the following ways without requiring your authorization. It should be noted that while not every use or disclosure will be listed, each of the ways we are permitted to use or disclose information will fall into one of the following areas:

      To provide, coordinate or manage your medical treatment and services. For instance, doctors, nurses and other professionals involved in your care, will use information in your medical record to plan a course of treatment for you that may include procedure, medications, tests, etc. We may also disclose your PHI to institutions and individuals outside of Starlight Health that are or will be providing treatment to you.
      To bill and receive payment for the treatment and services you received. For instance, we may forward information regarding your medical procedures and treatment to your employer to arrange payment for the services provided to you or we may use your information to prepare a bill to send to you or to the person responsible for your payment.  
      To run our practice, improve your care, and contact you when necessary. For example, we may use your PHI in order to conduct an evaluation of treatment and services we provide. 
      We may use your PHI to remind you about appointments and from time to time, to communicate with you about treatment alternatives and other health-related benefits and service that may be of interest to you.
      For workers’ compensation or similar programs.
      For public health safety issues such as preventing disease, helping with product recall, reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence.
      For a health oversight agencies.
      In response to a court order, subpoena, or warrant and to law enforcement officials in certain limited circumstances.
      RIGHTS THAT YOU HAVE
      When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

      You can ask to see or get an electronic or paper copy of your medical record, by filling out a Medical Record Authorization form and submitting it to our office. We will provide a copy of your medical record within 30 days of your request. 
      You can ask us to correct your medical record if you think it is incorrect or incomplete. You will need to complete a Health Information Amendment form and submit it to our office. We may decline your request, but we’ll tell you why in writing within 60 days.
      You can ask us not to share certain medical record information for treatment or payment.
      You can ask us to contact you in a certain way or at a certain location.
      You can ask for an accounting of the times we have shared your medical record for the last 6 years, who we shared it with and why.
      You can ask for a paper copy of this notice at any time.
      You can choose someone to whom information may be disclosed or if someone is your legal guardian, that person can make choices about your medical record.
      BREACH NOTIFICATION
      We are required to notify you in writing of any breach of your unsecured PHI as soon as possible, but in any event, no later than 60 days after we discovered the breach.

      BUSINESS ASSOCIATES
      At times it may be necessary for us to provide your PHI to one or more outside persons or organizations who assist us with our payment/billing activities and healthcare operations. In each case, we require these business associates and any of their subcontractors, to appropriately safeguard the privacy of your information.

      OUR NOTICE OF PRIVACY PRACTICE
      We are required by law to maintain the privacy of our patients’ PHI. We are required to abide by the terms of this Notice of Privacy Practice so long as it remains in effect. We reserve the right to change the terms of this Notice of Privacy Practice as necessary. You may receive a copy of any revised notice at any of our clinic locations. 

      EFFECTIVE DATE
      This Notice of Privacy Practice is effective April 1, 2020.

      QUESTIONS OR COMPLAINTS
      If you have questions or complaints regarding any part of this notice or our health information privacy policies, please contact the Privacy Officer listed above.

    • TELEHEALTH INFORMED CONSENT

                  Telehealth is the practice of healthcare using electronic communication or other information technology when you and your healthcare provider are in different locations.  Generally, healthcare providers can only treat patients who are physically located in the state where the provider is licensed.  In some cases, healthcare providers can treat patients who are in-state residents, but are temporarily located out-of-state (like on vacation).  Telehealth communications may include e-mail, facsimile, SMS/text/instant messaging, telephone, and video conferencing, and may be used on a variety of telephonic or electronic devices (collectively, “Communications”).  Your signature memorializes your informed consent and authorization for Practice and its providers to use Telehealth in the course of your care.  By signing this Telehealth Informed Consent and/or the underlying agreement, you acknowledge and understand the risks and benefits of receiving Telehealth, and you agree to the following terms of service. 

      Availability of Telehealth.  Sometimes telehealth can be more convenient and efficient than an in-person visit.  However, federal and state regulations limit telehealth in certain ways, including the prescription for controlled substances.  You must comply with all regulations and Practice Policies & Procedures that enable your provider to effectuate your care.
      Suitability of Telehealth.Telehealth should never be used in an emergency or urgent care situation.  If you experience a medical or psychiatric emergency, you must immediately call 911 or your local emergency department.  You must seek urgent care when you need it, and you must not rely on Telehealth for urgent health needs.  If you prefer in-person appointments instead of Telehealth, please tell your provider and Practice will accommodate your request or refer you to another provider.  Declining to receive Telehealth on a specific occasion will not impact your access to Telehealth in the future.
      Your provider has absolute discretion, at all times, to determine the suitability of delivering Telehealth.  If your provider determines that a different form of healthcare services is appropriate (like an in-person office visit), then your provider may discontinue Telehealth and will provide instructions and/or referrals for you to receive the recommended care.
      Telehealth has certain benefits, but it also has certain limitations and risks.  In some cases, transmitted information may be insufficient to allow for appropriate healthcare decision-making by your provider (like poor image resolution).  If your provider does not have access to information that would be apparent or available in a face-to-face visit, the use of Telehealth may result in medical error or misjudgment.  Delays can result from equipment deficiencies or failures.  No results can be guaranteed, and you are always free to seek a second opinion.  Telehealth never limits your ability to seek in-person care.
      At each Telehealth session you must be physically located in the state in which your provider is licensed.  If you are temporarily out-of-state, but maintain in-state residency, you must notify your provider before a Telehealth session commences.  You provider may not be able to issue prescriptions, referrals, or other orders if you are out-of-state.  You may need to seek local care for these and other healthcare needs.
      You will cooperate with your provider at each session to assess the suitability of Telehealth.  This may include verification of your identity, location, and readiness to proceed.  Telehealth requires that you be in a situation conducive to private, undistracted, and uninterrupted Communications.  If your health issue is of a sensitive nature, make sure you can receive Telehealth in a private space so others in your space cannot see, hear, or intercept your session.
      You can revoke this Telehealth Informed Consent at any time; however, your participation in Telehealth and Communications includes your implied consent.  If you revoke your consent, you must notify your provider and Practice in writing as soon as possible, and the revocation will not be effective until it has been received and acknowledged by your provider and Practice.
      Communications.Communications by their nature cannot be guaranteed to be secure or confidential.  Telehealth and Communications involve some risk that unauthorized persons or entities may see, access, copy, or use your personal information.  There is some risk that unencrypted Communications could be intercepted in transmission or redirected to a third-party that is not authorized to receive the information.  If you initiate a conversation in which you disclose protected health information on any Communication platform, then you authorize your provider and Practice to communicate with you regarding all protected health information in the same format.  Communications technology and platforms are wholly outside the control of your provider and Practice.  Therefore, your provider and Practice shall not be liable to you, or anyone, for any cost, damage, expense, injury, or other loss relating to Communications, including without limitation, malfunction or delay in response.
      Prior to receiving Telehealth, you must understand how Communications work and you need to be comfortable using them.  You must have the devices, tools, and telephone/internet access necessary to receive Telehealth, and you are responsible for the security of these elements.  It is your responsibility to encrypt medical information that you transmit electronically to your provider or Practice and failure to use technical safeguards, such as encryption, increases your risk of a privacy violation.  The risk of a violation of your privacy increases substantially when you enter information on a public access computer, use a computer that is on a shared network, allow a computer to store usernames and passwords, or employ a work computer for personal use.  You fully accept these risks and responsibilities.
      If Communications fail during the course of a Telehealth session, you must immediately try to contact your provider and/or Practice using another method of communication.  For example, if a video conference is disrupted by connectivity issues, you should call on the telephone.  Your session will then resume, or you and your provider may decide to reschedule.  Under no circumstances should you allow a health need to remain unaddressed because of Communications issues. 
      Privacy.Practice will adhere to its obligations regarding your privacy rights as identified in the Notice of Patient Privacy Practices.  You attest that you have read, understand, and agree to the Notice of Patient Privacy Practices and that you have been given a copy of the Notice or opted to use a digital copy.
      All Telehealth must be documented.  With your permission, Communications may be videotaped or otherwise recorded.  If you permit Telehealth sessions to be recorded, then the resulting data, including audio, image, and video files, may become part of your health record.
      The laws that affect your patient privacy are the same for Telehealth as they are for in-person care.  Among other considerations, this may include access that your health insurer will have to your records for quality review and audits.


      My signature below means that I have read this entire Telehealth Informed Consent, that I understand the risks and benefits of receiving Telehealth, and that I agree to the above-described terms of service.  If I had any questions, I have discussed them with my provider and all of my questions were answered to my satisfaction.  I will not sign this document until I am fully comfortable receiving Telehealth services.

    • Authorization to obtain Past Medical Records


      In order to establish ourselves as your healthcare provider, we may need to obtain your past medical records.  We do this in two major ways, first, we have access to the CORHIO medical system that many hospitals and practices across Colorado utilize to streamline medical information about patients.  Second, if you provide us with any specific providers which may or may not be affiliated with CORHIO we can contact them directly to obtain records from them.  We require additional documentation in order to contact them directly

      Information that Starlight Health is requesting access to including but not limited to:

      Discharge Summary
      Lab Results
      History & Physical
      Medication Lists
      X-Ray Reports
      Problem List
      Consultations
      Immunization Records
      Progress Notes
      List of Allergies
      Physician Orders

       

      EXPIRATION

      This authorization is valid for the lifetime of your membership.  Should you cancel your membership it automatically expires

       

      CORHIO NOTICE
      This medical facility is participating in the CORHIO health information exchange, which gives qualified medical professionals access to accurate, up-to-date patient information, and helps them provide better quality care.  HIPAA-covered providers who are caring for you can access your date; this is a very secure, controlled and private network

      An example of how this could help you:

      If you have a medical emergency and go to a local hospital or other participating providers, your records may be automatically logged and downloaded into your patient file here at Starlight Health.  

      We can pull your records for past labs, imaging records, visits from various facilities across the state

      Your records can sync across hospitals so in an emergency, the facility you went to could obtain your information even if you were unable to speak for yourself

      Starlight Health utilizes CORHIO for records retrieval only.  We do not upload any information about your care to the CORHIO system 

      By default you are opted-in to the CORHIO system however, you have the right to opt out of the CORHIO system. If you choose to opt out Starlight Health can block your records state wide so that no facility could share your records. (We do not recommend this as it will also prevent us from obtaining any of your records too, but it is your right.)

      If you wish to opt out of the CORHIO system you may do so by mailing the following letter directly to CORHIO: https://www.corhio.org/library/documents/For_Patients/corhio_opt_out_request__web_updated2.pdf

       


      Your Rights with Respect to This Authorization:

      Right to Receive Copy of This Authorization - I understand that if I agree to sign this authorization, which I am not required to do, I may obtain a signed copy by simply requesting Starlight Health for a copy.
      Right to Refuse to Sign This Authorization  - I understand that I am under no obligation to sign this form and that the person(s) and/or organization(s) listed above who I am authorizing to use and/or disclose my information may not condition treatment or payment, on my decision to sign this authorization.
      Right to Withdraw This Authorization  - I understand written notification is necessary to cancel this authorization. I am aware that the revocation will not apply to information that has already been released in response to this authorization. 

    • Membership Opt-In (Optional) 

    • Concierge Membership Agreement

      Welcome to a new world of healthcare and wellness, we are glad to have you as a member of Starlight Health.  This Agreement explains how our services may integrate with your benefits and how we will work together. 

      1. Membership Fee.  Practice charges a monthly membership Fee of $50 for Children & $100.00 for Adults.  This Fee is not related to any amenities, enhancements, or additional services; it is simply a monthly membership Fee.  This Fee is not a covered benefit under any Insurance plan including the Medicare program and you agree not to attempt reimbursement for this Fee.  By signing this Agreement, you acknowledge, understand, and agree that you are voluntarily paying this Fee out of pocket without expectation of third-party reimbursement.
      2. Relationship to Insurance.  It is important for us to know what kind of benefits you have so we can properly bill you for your share of cost.  If your benefits change at any time, you agree to let us know right away so we can uphold our legal obligations in this regard.
        1. In-Network.  For Insurances in which Practice participates, we will submit billings for reimbursement of charges for health Services that are a covered benefit.
          Out-of-Network.  For Insurances in which Practice does NOT participate, upon request 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.
        2. Medicare.  We will submit billings for reimbursement of charges for designated health services that are a Medicare covered benefit.  However, Medicare Advantage (Part C), Medi-Gap (Part F), and other Insurance plans may not reimburse for our charges.  It is important for us to know what kind of benefits you have so we can properly bill you for your share of cost.  If your benefits change at any time, you agree to let us know right away so we can uphold our legal obligations in this regard.
        3. Medicaid.  You specifically acknowledge that Practice and its providers do not accept Medicaid Patients into the Concierge Membership Program.  By signing this Agreement, you specifically acknowledge and agree that you are not currently a Medicaid recipient and if you become a Medicaid recipient in the future, you will promptly notify Practice so that we may discontinue your membership.
      3. 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.
      4. Exclusions.
        1. 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 and are not included in your membership.  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.
        2. Controlled Substances.  It is not our policy to prescribe chronic controlled substances on your behalf, including commonly abused opioid 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.
      5. Scheduling.  Your advance scheduling notice helps us provide the best possible experience for all of our patients.
        1. 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.
        2. 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.
        3. Urgent Care Instructions.  Practice operates during regular business hours and is not consistently available for care that requires immediate or urgent attention.  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 may be directed to go to your local urgent care center.
        4. 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 988.
      6. 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.
        1. 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 and effect unless revoked in writing and prior actions will not be affected by your revocation
      7. Privacy & Communications. 
        1. 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 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 that you have been given a copy of such or opted to use a digital copy.
        2. Methods of Communication.  You acknowledge that Practice communications may include use of cell phones, e-mail, facsimile, instant/MSM/text messaging, patient portal messages, 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, understand, and agree to our Telehealth Informed Consent and that you have been given a copy of such or opted to use a digital copy.
      8. Cessation.
        1. 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.
        2. You may end your membership upon 30 days’ written notice.  Your notice will be effective on the last day of the full month following receipt of your notice.
        3. If Practice elects to terminate this Agreement, we will provide you with 30 days’ written notice, or any such other time necessary to transition your care to another provider.
        4. There are certain circumstances in which we may choose to immediately terminate this Agreement including without limitation:
          1. You relocate outside our service area.
          2. Failure to pay Fees when they are due.
          3. Failure to sign our Telehealth Informed Consent, Controlled Substances Agreement, or other required documentation, as applicable.
          4. Failure to adhere to the recommended treatment plan, especially regarding the use of controlled substances.
          5. You are abusive, disruptive, or present an emotional, physical, or other danger to the wellbeing of patients, providers, staff, or others.
          6. Practice discontinues operation.
        5. 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.
      9. Miscellaneous.
        1. Amendment.  This Agreement may be amended by Practice from time to time.  Your continued engagement of Services will acknowledge your agreement to subsequent amendments.
        2. Default.  In the event of your default under this Agreement, Practice will be entitled to costs reasonably related to such default.
        3. 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 and county court actions brought by Practice shall be exempt from the requirements of this provision.
          1. It is understood that any claim of medical malpractice, including any claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered or omitted, will be determined by submission to binding arbitration in accordance with the provisions of part 2 of article 22 of title 13 of the Colorado Revised Statutes, and not by a lawsuit or resort to court process except as Colorado law provides for judicial review of arbitration proceedings.  The patient has the right to seek legal counsel concerning this Agreement, and has the right to rescind this Agreement by written notice to the physician within 90 days after the Agreement has been signed and executed by both parties unless said Agreement was signed in contemplation of the patient being hospitalized, in which case the Agreement may be rescinded by written notice to the physician within 90 days after release or discharge from the hospital or other health care institution.  Both parties to this Agreement, by entering into it, have agreed to the use of binding arbitration in lieu of having any such dispute decided in a court of law before a jury.
        4. Governing Law.  This Agreement shall be subject to and governed by the laws of Colorado 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.  This Agreement will be modified as necessary for compliance with emerging guidance related to public health matters and Practice reserves all rights arising thereunder.
        5. 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 Starlight 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 fictious or trade name and may include Practice’s physicians and/or providers, as applicable; (iii) “you” and “your” reference the individual receiving Services under this Agreement, and/or the legally responsible individual (as applicable); (iv) “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; (v) “Insurance” means health insurance plans, PPO or HMO plans, prepaid health plans, Medicaid, Medicare, other state and/or federal public healthcare programs, and substitute healthcare coverage (as applicable); (v) “Patient Policies & Procedures” means Practice’s written documents and unwritten customs that inform its operations; and other capitalized terms have the definitions ascribed to them by law and regulation.
        6. 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.
        7. 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.
        8. 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, by statute, at common law, in equity, or otherwise.  All such Remedies may be exercised separately or concurrently, in such order and as often as may be deemed desirable by Practice.
        9. 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.
          1. 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.
        10. Survival.  Any provisions creating obligations extending beyond the term of this Agreement shall survive its expiration or termination, regardless of the reason, whether or not the right of survival was explicitly reserved.
        11. 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 and bill for the Fees and charges described herein (including without limitation the share of cost due under your health plan, as applicable) 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.
        12. 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.

       

       

    • Direct Primary Care Membership Agreement

      Welcome to a new world of healthcare and wellness, we are glad to have you as a member of Starlight Health.  As part of your membership, 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.
        1. In-person Office Visits.  If you choose to be seen in our office, we will generally have a same-day appointment available for you.  We will always schedule sufficient time to thoroughly discuss your healthcare.
        2. 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 membership and we are swift to respond to your needs. 
        3. Annual Exam.  Your health and longevity are best served by periodic oversight.  Therefore, we may perform an annual physical examination to monitor existing health conditions and recommend preventative treatments.
        4. Women’s Health.  Gynecological care is vital and is included in your membership (however, obstetric services are not included). 
        5. In-Office Ancillary Services.  Your care may require in-office ancillary services such as certain laboratory tests or electrocardiography.  Most ancillary services are included in the Periodic Fee, but some, like specialty dispensed medications, may have an Itemized Charge that is in addition to the Periodic Fee.
        6. 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.  Once a specialist consultation is complete, we will continue to work with your specialist to coordinate care with our office.  While hospitalist and skilled nursing facility care are not a part of your membership, if you are admitted to a hospital or skilled nursing facility, we will work diligently with those providers to facilitate the best care available.
      2. Exclusions.
        1. 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 and are not included in your membership or the Periodic Fee.  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.
        2. Controlled Substances.  It is not our policy to prescribe chronic controlled substances on your behalf, including commonly abused opioid 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 to provide the best possible experience for all of our patients.
        1. 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.
        2. 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.
        3. Urgent Care Instructions.  Practice operates during regular business hours and is not consistently available for care that requires immediate or urgent attention.  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 may be directed to go to your local urgent care center.
        4. 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 988.
      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.
        1. 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 and effect unless revoked in writing and prior actions will not be affected by your revocation.
      5. Privacy & Communications. 
        1. 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 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 that you have been given a copy of such or opted to use a digital copy.
        2. Methods of Communication.  You acknowledge that Practice communications may include use of cell phones, e-mail, facsimile, instant/MSM/text messaging, patient portal messages, 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, understand, and agree to our Telehealth Informed Consent and that you have been given a copy of such or opted to use a digital copy.
      6. Fees.  In exchange for Services, you agree to pay Practice the Fees as described in Attachment A.
      7. Cessation.
        1. Your membership is for one year and will automatically renew until you decide not to renew.  Both you and Practice shall have the absolute and unconditional right to terminate this Agreement without cause.
        2. You may end your membership upon 30 days’ written notice.  Your notice will be effective on the last day of the full month following receipt of your notice.
        3. If Practice elects to terminate this Agreement, we will provide you with 30 days’ written notice, or any such other time necessary to transition your care to another provider.
        4. There are certain circumstances in which Practice may choose to immediately terminate this Agreement including without limitation: You relocate outside our service area.
          1. Failure to pay Fees when they are due.
          2. Failure to sign our Telehealth Informed Consent, Controlled Substances Agreement, or other required documentation, as applicable.
          3. Failure to adhere to the recommended treatment plan, especially regarding the use of controlled substances.
          4. You are abusive, disruptive, or present an emotional, physical, or other danger to the wellbeing of patients, providers, staff, or others.
          5. Practice discontinues operation.
        5. 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.
      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.  Services under this Agreement may not be submitted as a fee-for-service claim for payment to an Insurance issuer and some Services may be a no-cost covered benefit under your Insurance, if any.  This Agreement is solely for the described Services and it does not cover hospital, specialist, or any services not directly provided to you by Practice.
        1. Non-Participation in Insurance.  For purposes of this Agreement, 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.
        2. Non-Participation in Medicaid.  For purposes of this Agreement, Practice and its providers do not participate in Colorado’s Medicaid program.  Under state law, non-participating healthcare providers cannot provide medical services to Medicaid recipients.  This means that Medicaid cannot be billed for any Services performed under this Agreement.  Further, you agree not to bill Medicaid or attempt Medicaid reimbursement for any such Services.  By signing this Agreement, you specifically acknowledge and agree that you are not currently a Medicaid recipient and if you become a Medicaid recipient in the future, you will promptly notify Practice and transfer your care to another provider.
        3. Non-Participation in Medicare.  For purposes of this Agreement, Practice and its providers do not participate in the Medicare program.  This means that 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 you are not currently a Medicare beneficiary and if you become a Medicare beneficiary in the future, you will immediately notify Practice so that we may uphold our legal obligations.
        4. 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).  If your care is subject to the No Surprises Act or state law corollaries, 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.
      9.  Miscellaneous.
        1. Amendment.  This Agreement may be amended by Practice from time to time.  Your continued engagement of Services will acknowledge your agreement to subsequent amendments.
        2. Default.  In the event of your default under this Agreement, Practice will be entitled to costs reasonably related to such default.
        3. 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 and county court actions brought by Practice shall be exempt from the requirements of this provision.   
          1. It is understood that any claim of medical malpractice, including any claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered or omitted, will be determined by submission to binding arbitration in accordance with the provisions of part 2 of article 22 of title 13 of the Colorado Revised Statutes, and not by a lawsuit or resort to court process except as Colorado law provides for judicial review of arbitration proceedings.  The patient has the right to seek legal counsel concerning this Agreement, and has the right to rescind this Agreement by written notice to the physician within 90 days after the Agreement has been signed and executed by both parties unless said Agreement was signed in contemplation of the patient being hospitalized, in which case the Agreement may be rescinded by written notice to the physician within 90 days after release or discharge from the hospital or other health care institution.  Both parties to this Agreement, by entering into it, have agreed to the use of binding arbitration in lieu of having any such dispute decided in a court of law before a jury.
        4. Governing Law.  This Agreement shall be subject to and governed by the laws of Colorado 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.  This Agreement will be modified as necessary for compliance with emerging guidance related to public health matters and Practice reserves all rights arising thereunder.
        5. 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 Direct Primary Care Membership 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 fictious or trade name and may include Practice’s physicians and/or providers, as applicable; (iii) “you” and “your” reference the individual receiving Services under this Agreement, and/or the legally responsible individual (as applicable); (iv) “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; (v) “Insurance” means health insurance plans, PPO or HMO plans, prepaid health plans, Medicaid, Medicare, other state and/or federal public healthcare programs, and substitute healthcare coverage (as applicable); (v) “Patient Policies & Procedures” means Practice’s written documents and unwritten customs that inform its operations; and other capitalized terms have the definitions ascribed to them by law and regulation.
        6. Integration.  This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes any and all other verbal or written agreements, representations, negotiations, and understandings.
        7. 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.  No party may raise a defense to the formation or enforceability of this Agreement due to electronic delivery.
        8. 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, by statute, at common law, in equity, or otherwise.  All such Remedies may be exercised separately or concurrently, in such order and as often as may be deemed desirable by Practice.
        9. 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.
        10. 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.
        11. Survival.  Any provisions creating obligations extending beyond the term of this Agreement shall survive its expiration or termination, regardless of the reason, whether or not the right of survival was explicitly reserved.
        12. 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 and bill for the Fees and charges described herein (including without limitation the share of cost due under your health plan, as applicable) 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.
        13. 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.

        

      Attachment A

      Fees

      In exchange for Services, you agree to pay Practice the following Fees.

      1. Enrollment Fee.  The Enrollment Fee is $50.00.  The Enrollment Fee covers the initial administrative cost of establishing your membership and is not related to the provision of Services.
      2. Periodic Fee.  The Periodic Fee is due no later than the first day of your membership and is payable by automatic debit from your bank or credit card account by the first day of each month thereafter.  In order to remain financially viable, Practice reserves the right to change its Fees at any time with 30 days’ notice to you, but not more than once per calendar year.  The Periodic Fee for your membership is identified below.
        Age: 4-17 - $50/mo | $600/yr
        Age: 18+ - $100/mo | $1200/yr
        1. Minor children must be enrolled with at least one parent or guardian.
      3. 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.
        1. State law does not permit Practice to bill any Insurance plan for Services that are included in your membership.  However, Itemized Charges are not included in your membership and incur a separate and additional Fee.  If you have Insurance that covers your Itemized Charges, you must notify Practice in advance of the Services being performed.  In such a case, for Insurances in which Practice participates, we will submit billings for reimbursement of Itemized Charges.  For Insurances in which Practice does not participate, upon request we will provide you with documentation so you may submit for your own reimbursement of Itemized Charges.
      4. Late Fee.  Your membership renewal Annual Fee is due 30 days prior to the expiration of your current membership.  If your membership renewal fee is not received by the due date, you may be charged a late fee equal to 10% of the membership renewal Annual Fee.  If you elect to pay your Annual Fee in monthly installments and your payment is not received by the due date, you may be charged a late fee.
      5. Re-enrollment.  If you choose to discontinue your membership and you later wish to re-enroll, we reserve the right to decline re-enrollment or require you to pay a re-enrollment fee that is equivalent to the months of absent payments while you were not enrolled as a member, not to exceed 12 months.
      6. Refunds.  If you terminate this Agreement without cause, any remaining membership fee will be prorated.  You will be refunded the prorated membership fee, minus the actual value of professional services rendered to you while the Agreement was in effect.  If Practice terminates this Agreement pursuant to section 7.d, then no refund will be issued.
      7. Employer Sponsored Membership.  If your membership is being paid for by your employer, the applicable terms of the Employer Sponsorship Agreement are incorporated by reference as though fully set forth herein.  If your employer sponsorship ceases but you continue your membership, the Fees then in effect shall apply to your continued membership.
    • Signature 

    • Signature Page

      Your signature below means that you have read, understand, and agree to all of the terms contained in all Agreements, the Telehealth Informed Consent, the Notice of Patient Privacy Practices, the Controlled Substances Agreement, along with any appendices, attachments, exhibits, or schedules hereto, and you agree to abide by Practice’s Patient Policies & Procedures as amended from time to time.  If you are enrolling a patient 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.

            Note: by signing this form you are agreeing to have any issue of medical malpractice decided by neutral binding arbitration rather than by a jury or court trial.  You have the right to seek legal counsel and you have the right to rescind this Agreement within 90 days from the date of signature by both parties unless the Agreement was signed in contemplation of hospitalization in which case you have 90 days after discharge or release from the hospital to rescind the agreement.  No health care provider shall withhold the provision of emergency medical services to any person because of that person's failure or refusal to sign an agreement containing a provision for binding arbitration of any dispute arising as to professional negligence of the provider.  No health care provider shall refuse to provide medical care services to any patient solely because such patient refused to sign such an agreement or exercised the ninety-day right of rescission.

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