NARCOTICS POLICY: Direct Functional Medicine does not manage chronic pain with narcotic prescriptions. If you are in need of chronic pain management, please seek care at a pain management clinic.
MEMBERSHIP. Patient hereby agrees to enroll as a member in Practice’s Functional Medicine membership program (“Membership Program”) for six months, beginning on the Effective Date set forth above. By being a member of the program, Patient shall be eligible to receive functional medicine care and shall be subject to the conditions and limitations described therein. Functional medicine care does not include primary care services.
MEMBERSHIP FEES. Patient agrees to pay for six months of membership in the Functional Medicine program. This one-time fee is due on the Effective Date hereof. After six months, memberships convert to a monthly charge to continue care. It is the Patient's responsibility to maintain an up-to-date credit/debit card number on file.
CANCELLATION. 30 days notice is required for cancellation of membership. Memberships in the monthly charge period (after six months) who cards on file that reject their monthly membership draft have 30 days to place a new card on file and notify the practice or be terminated.
INITIAL APPOINTMENT CANCELLATION. Any patient who has not completed their new patient paperwork, or does not have their credit card on file with the practice 72 hours prior to their appoint, that appointment will be cancelled.
24 HOUR CANCELLATION AND RESCHEDULING POLICY. If follow up appointment cancellation is necessary, practice requires that you call or reschedule online at least 24 hours in advance. Your advanced notice will allow another patient access to that appointment time. Late cancellations and no-shows will be billed a twenty dollars ($20) missed appointment fee.
CHANGES TO MEMBERSHIP FEE SCHEDULE. Practice may amend the Membership Fee Schedule at any time, as it may determine in its sole discretion, upon providing Patient at least 60 days advance written notice.
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 Practice but not specifically described on Exhibit A.
The Practice strongly encourages 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.
Functional Medicine memberships include an initial appointment of up to 90 minutes, during which a patient history and physical assessment are conducted. Any necessary blood work or specialty labs will be discussed at this time, with labs paid separately from the membership. In addition, patients receive up to 5 follow-up appointments. Any additional follow-up appointments are charged at $150 each. Members may also send up to 3 messages of 200 words or less; messages longer than this will incur a charge of $30 per reply or will require a follow-up visit.
After the initial 6-month membership, patients who are still working through their health concerns may continue care for $150 per month until they reach their goals or choose to stop. This includes 1 follow-up visit and a 200-word message each month. A 30-day notice is required to cancel any membership.
INSURANCE. Patient acknowledges and understands that this Membership Agreement or Membership in Practice does not provide comprehensive health insurance coverage,
nor is it a contract of insurance. Patient represents that patient has contacted Patients health insurance company to discuss any limitations or restrictions that me be imposed upon patient by signing the agreement for self-pay status attached here to and incorporated by reference herein.
INSURANCE CLAIMS. Patient acknowledges and understands that Practice is not a participating provider in any Medicaid, Medicare or private health care plan. Patient acknowledges and understands that Practice will not bill insurance carriers on Patient’s behalf for Covered Services provided to Patient, and 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 Practice under this Membership Agreement. Membership Fees may not be submitted to insurance companies for reimbursement. Many labs can be obtained through LabCorp which can bill your insurance company. Patient is responsible to understand their insurance benefits regarding labs and deductibles. Practice will not communicate with your insurance company or LabCorp regarding your bill. Practice offers discounted rates through LabCorp that are often cheaper than what insurance provides. It is the patient’s responsibility to let Practice know which rates they wish to use. Practice in unable to change these charges once accrued.
TAX-ADVANTAGED MEDICAL SAVINGS ACCOUNTS. It is the patient’s responsibility to communicate with their HSA (Health Savings Account), MSA (Medical Savings Account), or FSA (Flexible Savings Account) benefit advisor to determine if the membership fees constitute eligible medical expenses that are payable or reimbursable under their plan. Any charges accrued from services rendered by the Practice that are denied by the Patient’s third-party payer remain the Patient’s responsibility and must be paid in full by the Patient.
HEALTH PLANS. Because Practice is not a participating provider in Medicaid, Medicare or private health care plan, third party payers may not count the Membership Fees incurred pursuant to this Membership Agreement toward any deductible Patient may have under a health plan. Patient acknowledges through this Membership Agreement that neither Practice, nor its Providers, participate in any health insurance, Medicaid, HMO plans or panels, and have opted out of Medicare.
Patient acknowledges through this Membership Agreement that Patient understands this Membership Agreement is not an insurance plan or a substitute for health insurance. Patient understands that this Membership Agreement does not replace any existing or future health insurance or health plan coverage that the Patient may carry. The Agreement does not include hospital services, or any services not personally provided by Practice or its staff. The Patient acknowledges by signing this agreement that the Patient has been advised to obtain or keep in full force, health insurance that will cover hospitalizations, catastrophic events, and all other healthcare services not personally provided by Practice.
MAINTAINING SEPARATE PRIMARY CARE ACCESS. Practice does not replace care currently provided to the member by other care teams, such as internists, gynecologists, cardiologists, gastroenterologists, pediatricians, and oncologist or any other specialty care provider. Practice does not function as a primary care provider, rather the practice acts as an extension of the patient’s medical team working on root-cause resolution. Patient should not discontinue any prescription medications without first consulting their prescribing provider. Patient must maintain a relationship with an outside primary care provider to provider emergency and urgent care. If a member encounters a medical emergency and is not able to receive care from their primary care provider, patient is required to call 911 or report to the nearest emergency department.
NONPARTICIPATION IN LEGAL MATTERS. Patients involved in legal proceedings pertaining to consequences of symptoms regarding diagnoses, health, work capabilities, or disability, this is not a reason to seek care from Practice in anticipation of legal counsel. By signing below, patient affirms they are not currently involved in legal proceedings in regard to health (mental, physical or otherwise), nor do they intend to pursue legal proceedings related to their medical conditions. Should Practice asked for expert opinion, witness, or paperwork to submit in a court case, patient agrees to pay $700 per hour for provider services in addition to fee to retain an attorney. A retainer to Practice of $20,000 is required. Practice does not complete paperwork for FMLA or disability.
PORTAL MESSAGING ETTIQUETTE. Please do not send message via email, utilize our HIPPA secured portal for all communications. These messages are a permanent part of your medical chart. This is to be used for non-urgent needs only, and a response will generally be sent within 2 business days. Messages that are too long or too complex may require a follow-up appointment online or in clinic. This ensures that we can provide comprehensive care and evaluate your condition thoroughly. Patient may use an included visit or pay a fee according to time needed to consult with patient. Patient understands that the portal messaging is not an appropriate means of communication regarding emergency or other time-sensitive issues. In the event of an emergency, the patient must call 911 or report to the nearest emergency department.
TERMINATION OF AGREEMENT. Termination of this Membership Agreement shall cause the termination of Patient’s membership in the Membership Program described herein. No more than a 30-day medication refill can be provided with the mandatory 30-day notice of termination.
TERMINATION BY PRACTICE. Practice may terminate this Membership Agreement upon providing Patient advance written notice.
TERMINATION BY PATIENT. Patient may terminate this Membership Agreement at any time and for any reason, upon providing 30 days advance written notice to Practice. Such termination shall be effective on the last day of the then-current membership month. Membership Fees shall not be pro-rated for any terminal month or membership period. 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.
INDEMNIFICATION. Patient agrees to indemnify and to hold 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 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.
WAIVER. The waiver of either Practice or Patient of a breach of any provisions of this Membership Agreement must be in writing and signed by the waiving party to be effective and shall not operate or be construed as a waiver of any subsequent breach by either Practice or Patient.
GOVERNING LAW. This Agreement and the rights and obligations of Practice and Patient hereunder shall be construed and enforced pursuant to the laws of the State of North Carolina.
CHANGE OF LAW. If there is a change of any law, regulation or rule, federal, state or local, which affects this Membership Agreement, any terms or conditions incorporated by reference in this Membership Agreement, the activities of Practice under this Membership Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and Practice reasonably believes in good faith that the change will have a substantial adverse effect on Practice’s rights, obligations or operations associated with this Membership Agreement, then Practice may, upon written notice, require the Patient to enter into good faith negotiations to renegotiate the terms of this Membership Agreement. If the parties are unable to reach an agreement concerning the modification of this Membership Agreement with ten (10) days after the effective date of change, then Practice may immediately terminate this Membership Agreement upon providing written notice to the Patient.
ASSIGNMENT/BINDING EFFECT. This Membership Agreement shall be binding upon and shall inure to the benefit of both Practice and Patient and their respective successors, heirs and legal representatives. Neither this Membership Agreement, nor any rights hereunder, may be assigned by the Patient without the written consent of Practice.
I understand if I have an unpaid balance to Direct Functional Medicine Mebane and do not make satisfactory payment arrangements, my account may be placed with an external collection agency. I will be responsible for reimbursement of the fee of any collection agency, which may be based on a percentage at a maximum of 35% of the debt, and all costs and expenses, including reasonable collection and attorney’s fees incurred during collection efforts.
In order for Direct Functional Medicine Mebane or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that Direct Functional Medicine Mebane and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable. Furthermore, I consent the designated external collection agency to share personal contact and account related information with third party vendors to communicate account related information via telephone, text, e-mail, and mail notification.
IN WITNESS WHEREOF, the parties have caused this Membership Agreement to be effective on the Effective Date first written above.