DIRECT PRIMARY CARE MEMBERSHIP AGREEMENT
Membership Patient hereby agrees to enroll as a member in the Practice’s direct primary care membership program (“Membership Program”) beginning on the Effective Date set forth above. By being a member of the program, Patient shall be eligible to receive certain basic medical services described on Exhibit A (“Covered Services”), attached hereto and made a part hereof, and shall be subject to the conditions and limitations described therein.
Membership in the Practice’s Membership Program includes only the Covered Services specifically described in Exhibit A. The Practice may add or discontinue Covered Services at any time, as it may choose in its sole discretion. The Practice shall provide at least thirty (30) days’ advance written notice upon any change to the Covered Services listed in Exhibit A. Visits are not transferable between
family members.
Membership Fees In addition to the one-time non-refundable registration fee in the amount of Fifty Dollars ($125.00) per Patient, Patient agrees to pay a monthly fee (“Membership Fee”) in accordance with the schedule available at Bottumzup Health and Wellness, LLC. The one-time registration fee is due at the time of application. The initial monthly fee is due prior to the Effective Date (date of the first visit with Karen Molina Melendez, APRN) when the Patient is accepted into the Practice. Thereafter, Membership Fees shall be due on the fifteenth (15) day of each month following the Effective Date and will cover the Patient’s membership for that month. Membership Fees shall be pro-rated for first month. only. Any fees or charges that are not included in the Membership Fee (i.e. fees for non-covered services) shall be due at the time of service.
A. Late Fee. In the event that Patient is unable to pay the monthly Membership Fee in full and on time, Patient shall be charged a late fee of Fifty Dollars ($50.00)
and the Practice may, in its sole discretion, terminate this Membership Agreement. There will be a 5-day Grace Period. B. Changes to Membership Fee Schedule. The Practice may amend the Membership Fee Schedule at any time, as it may determine in its sole discretion, upon providing Patient at least sixty (60) days’ advance written notice.
SERVICES: I understand that Bottumzup Health and Wellness, LLC is not an insurance plan and DOES NOT PROVIDE COMPREHENSIVE HEALTH INSURANCE COVERAGE, nor is this a contract of insurance. I understand that Bottumzup Health and Wellness, LLC will make available: (a) certain medical services as requested by me or as deemed necessary by the Practitioners in accordance with the established standard of care for primary care practitioners; and (b) certain related services (such medical services and related services are referred to in this Agreement collectively as “Services” and described in further detail in Attachment A).
NON-COVERED SERVICES Patient understands and acknowledges that Patient is responsible for any charges incurred for health care services performed outside of the physical office space location as set forth above, including, but not limited to, emergency room visits, hospital and specialist care, and imaging and lab tests performed by third parties. Patient shall also be responsible for any charges incurred for health care services provided by the Practice but not specifically described on Exhibit A.
**The Practice strongley encourages the Patient to maintain health insurance during the term of this Membership Agreement to cover services that are not provided under this Membership Agreement. Patient should purchase health insurance to cover, at a minimum unpredictable and catastrophic expenses.
INSURANCE Patient acknowledges and understands that this Membership Agreement or Membership in the Practice does not provide comprehensive health insurance coverage, nor is it a contract of insurance. Patient represents that patient has contacted Patients insurance health insurance company to discuss any limitations or restrictions that me be imposed upon patient by signing the agreement for self-pay status attached hereto and incorporated by reference herein.
TERMINATION BY PATIENT Patient may terminate this Membership Agreement at any time and for any reason, upon providing advance written notice to Practice (60days). Such termination shall be effective on the last day of the then-current calendar month. Membership Fees shall not be pro-rated for any terminal month. Monthly Membership Fees will continue to accrue until Patient’s written notice of termination is received by Practice at its office location set forth above.
Termination by Practice: I understand that Bottumzup Health and Wellness, LLC may also terminate this Agreement and the provider-patient relationship with me upon thirty (30) days’ prior written notice if any Membership Fee payment is more than fifteen (15) days late and at any other time upon ninety (90) days’ prior written notice; in such case, Bottumzup Health and Wellness, LLC will provide me with information to assist me in finding another primary care physician to take over my care.
INSURANCE CLAIMS Patient acknowledges and understands that the Practice is not a participating provider in any Medicaid or private health care plan. Patient acknowledges and understands that the Practice will not bill insurance carriers on Patient’s behalf for Covered Services provided to patient and the Practice will not bill any health care plan of which the Patient may be a subscriber or beneficiary for Membership Fees due and owing to the Practice under this Membership Agreement. Membership Fees may not be submitted to insurance companies for reimbursement.
INDEMNIFICATION Patient agrees to indemnify and to hold the Practice and its members, officers, directors, agents, and employees harmless from and against all demands, claims, actions or causes of action, assessments, losses, damages, liabilities, costs and expenses, including interest, penalties, attorney fees, etc. which are imposed upon or incurred by the Practice as a result of the Patient’s breach of any of Patient’s obligations under this Agreement.
ENTIRE AGREEMENT This Membership Agreement constitutes the entire understanding between the parties hereto relating to the matters herein contained and shall not be modified or amended except in a writing signed by both parties hereto.
IN WITNESS WHEREOF, the parties have caused this Membership Agreement to be effective on the Effective Date first above written.
Bottumuzup Health and Wellness, LLC, a
Florida limited liability company