Program Services and Payment Terms

1.     Medical Services. As used in this Agreement, the term Medical Services shall mean those medical

services that the Physician himself is permitted to perform under the laws of the State of Indiana and that are consistent with his training and experience as an Internal Medicine/Peds, or Internal Medicine/Cardiology physician, as the case may be. In addition to the Initial Preventive Physical Exam and the Annual Wellness Visit, Patient shall also be entitled to an annual comprehensive wellness examination and evaluation, which shall be performed by the Physician, and include some or all of the following, as deemed appropriate by Physician:

a. Health Risk Assessment

b. Vision and Hearing Screening

c. Pulmonary Function Testing

d. EKG

e. Body Fat Analysis

f. Bone Density

g. Psychosocial Screening

h. Custom Wellness Plan to Include Exercise and/or [ Plan

i. Certain in-house labs

j. Blood draws

k. Immunizations

l. Minor procedures

m. Treadmill evaluations

It is anticipated that many of the services and tests associated with the comprehensive exam will not be covered by health insurance, Medicare, or other third-party reimbursement. Any such services performed as part of the comprehensive exam that are not covered by insurance or Medicare are provided as a benefit of your membership fee.

Medicare and private health insurance companies require CCSI to collect from patients all applicable charges for health care services that are patient's responsibility according to your health plan agreement; these are listed as such on the Explanation of Benefits (EOB Therefore, you are financially responsible for the following charges, which are not part of the Membership Fee:

• Co-insurance and/or deductibles for any health care services received.
• Charges for health care services not covered by health insurance for any reason.
• Co-payments if we are unable to waive them due to your health plan or Medicare requirements.

The annual membership fee will be applied to satisfy any co-pays required by specific insurance plans for health care services that are patient's responsibility to the extent possible. Patient will be responsible for any co-pays that exceed the membership fee.

 

Patient represents and warrants that his/her health insurance information set forth below is accurate and that he/she will notify CCSI of any changes to this information. 

 

 

PATIENT AGREEMENT

Concierge Care of Southern Indiana, L.L.C.

This is an Agreement entered into on {date} between Concierge Care of Southern Indiana, L.L.C. ("CCSI") an Indiana Limited Liability Company, located at 500 Lafollette Station Drive, Floyds Knobs, IN 47119, Daniel J. Eichenberger, M.D.,D. Mark Bickers, M.D. and Dr. Christina Minrath ("Physicians") in their capacity as agents of CCSI and you, {printedName} (Patient)

Background

     Physicians specialize in Internal Medicine/Peds, and Internal Medicine/Cardiology, respectively, and will deliver care on behalf of CCSI, at the address set forth above. In exchange for certain fees paid by You, CCSI, through Physicians, agrees to provide Patient with the program services described in this Agreement on the terms and conditions set forth in this Agreement.

Definitions

1. Patient. A patient is defined as those persons for whom the Physician shall provide Program Services, and who are signatories to, or listed on the documents attached as Appendix 1, and incorporated by reference, to this Agreement

2. Program Services. As used in this Agreement, the term program services shall mean uninsured medical, non- Medical, and certain benefits, which CCSI offers and specifically described in Appendix 1.

3. Fees. In exchange for the program services, the Patient agrees to pay CCSI, the annual membership fee identified therein. This fee is payable as provided in Appendix 1 and is payment for the program services provided to the Patient during this Agreement.

4. Covered Health Care Services Excluded from Membership Fee. The annual membership fee covers the costs of the program services. The membership fee does not cover the cost of any health care services provided and covered by health insurance or Medicare. Further, fees paid under this Agreement are not covered by your health insurance or Medicare and are not designed or intended as compensation for services covered by such plans.

5. Participation in Insurance. Patient acknowledges that neither CCSI nor the Physicians participate in all health insurance or HMO plans or panels and therefore may be considered a non-participating provider for some plans applicable to the patient. The Patient shall retain full and complete responsibility for any such determination. Nothing in this Agreement supersedes or modifies the terms or conditions of any agreements related to your health insurance. CSSI will, as a convenience to Patient, bill your health insurer or Medicare for all insured health care services. Patient agrees to sign the required Medicare and Medi-Gap Acknowledgment Form attached as Concierge Care of Southern Indiana, LLC. "The Way Medicine Was Meant to Be" Appendix 2 and any assignment of benefits required by any health insurer.

6. Insurance or Other Medical Coverage. Patient acknowledges and understands that this Agreement is not an insurance plan and not intended to replace any existing health insurance or other health plan coverage (such as membership in an HMO) that Patient may carry. This Agreement will not cover hospital services, or any healthcare services not personally provided by CCSI or its Physicians. Patient acknowledges that CCSI has advised Patient to obtain or keep in full force such health insurance policy(ies) or plans that will cover Patient for general healthcare costs.

 

7. Term; Termination. This Agreement will commence on the date listed in Appendix 1 and auto-renew on a yearly basis unless terminated. Both Patient and CCSI, however, shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination, upon giving 30 days prior written notice to the other party. Unless previously terminated as set forth above, at the expiration of the initial one-year term (and each succeeding yearly term), the Agreement will automatically renew for successive yearly terms upon the payment of the applicable fee.

 

8. Communications. You acknowledge that communications with the Physician using Email, facsimile, video chat, instant messaging, and cell phone are not guaranteed to be secure or confidential communication methods. As such, you expressly waive the Physician's obligation to guarantee confidentiality with respect to correspondence via such means of communication. You also acknowledge that all such communications may become a part of your medical record. By providing Patient's email address on the attached Appendix 1, Patient authorizes CCSI and its Physicians to communicate with Patient by Email regarding Patient's "protected health information" (PHI) (as that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and it's implementing regulations Patient acknowledges that:

1. Email is not necessarily a secure medium for sending or receiving PHI and, there is always a possibility that a third party may gain access.
2. Although the Physician will make reasonable efforts to keep email communications confidential and secure, neither CCSI nor the Physician can assure or guarantee the absolute confidentiality
3. In the discretion of the Physician, email communications may be made a part of Patient's permanent medical record; and,
4. Patient understands and agrees that Email is not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation in which the Member could reasonably expect to develop into an emergency, Member shall call 911 or the nearest Emergency room and follow the directions of emergency personnel.

If Patient does not receive a response to an email message within one day, Patient agrees to use another means of communication to contact the Physician. Neither CCSI nor the Physician will be liable to Patient for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient as a result of technological failures, including, but not limited to, (i) technological failures attributable to any internet service provider, (ii) power outages, failure of any electronic messaging software, or failure to properly address email messages, (iii) failure of the Practice's computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of email communications by a third party; or (v) Patient's failure to comply with the guidelines regarding the use of email communications set forth in this paragraph.

 

9. Change of Law. If there is a change of any law, regulation or rule, federal, state, or local, which affects the Agreement including these Terms & Conditions, which are incorporated by reference in the Agreement, or the activities of either party under the Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and either party reasonably believes in good faith that the change will have a substantial adverse effect on that party's rights, obligations or operations associated with the Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms of the Agreement including these Terms & Conditions. If the parties are unable to reach an agreement concerning the modification of the Agreement within forty-five days after of date of the effective date of change, then either party may immediately terminate the Agreement by written notice to the other party.

 

10. Severability. If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of the Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable.

 

11. Reimbursement for services rendered. If this Agreement is held to be invalid for any reason, and if CCSI is therefore required to refund all or any portion of the membership fees paid by Patient, Patient agrees to pay CCSI an amount equal to the reasonable value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid.

 

12. Amendment. No amendment of this Agreement shall be binding on a party unless it is made in writing and signed by all the parties. Notwithstanding the foregoing, the Physician may unilaterally amend this Agreement to the extent required by federal, state, or local law or regulation ("Applicable Law") by sending Patient 30 days advance written notice of any such change. Any such changes are incorporated by reference into this Agreement without the need for signature by the parties and are effective as of the date established by CCSI.

 

13. Assignment. This Agreement and any rights Patient may have under it may not be assigned or transferred by

 

14. Relationship of Parties. Patient and Physicians intend and agree that the Physicians, in performing their duties under this Agreement, are independent contractors, as defined by the guidelines promulgated by the United States Internal Revenue Service and/or the United States Department of Labor, and the Physicians shall have exclusive control of their work and the manner in which it is performed.

 

15. Legal Significance. Patient acknowledges that this Agreement is a legal document and creates certain rights and responsibilities. Patient also acknowledges having had a reasonable time to seek legal advice regarding the Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of the Agreement.

 

16. Miscellaneous. Physicians reserve the right to treat non-members at their discretion and, if necessary, as long as their obligations to Members are fully satisfied.

 

17. Entire Agreement: This Agreement contains the entire Agreement between the parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement.

 

18. Jurisdiction: This Agreement shall be governed and construed under the laws of the State of Indiana, and all disputes arising out of this Agreement shall be settled in a court in Floyd County, Indiana.

 

19. SERVICE. All written notices are deemed served if sent to the address of the party written above or appearing in Exhibit A by first class U.S. mail.

 

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

 

2.       Disability and FMLA forms. CCSI will complete requested disability and FMLA forms as a benefit

3.       Laboratory Testing. Should patient require laboratory testing, CCSI will draw blood and/or collect

other bodily fluids necessary to facilitate the required tests. CCSI will not bill patient for any fees associated with drawing blood or collecting bodily fluids. CCSI contracts with a third-party laboratory to perform these tests. Patient will be responsible for the cost of the laboratory test itself if not covered by health insurance or Medicare. In addition, if patient requires additional or different tests that are not offered by the third-party laboratory with which CCSI has an agreement, Patient will be responsible for the costs of any such testing at a different laboratory if not covered by health insurance or Medicare. Uninsured labs or screenings provided in the office are included in the membership fee.

4.       Physician Absence. Physicians may, from time to time, due to vacations, sick days, and other similar situations, not be available to provide the services referred to above in this paragraph 1. During such times, Patient's calls to the Physician or to the Physician's office will be directed to a physician who is "covering" for the Physician during his absence. CCSI will make every effort to arrange for satisfactory coverage during times of vacation and/or absence.

5.     Non-Medical, Personalized Services. CCSI shall also provide Patient with the following non-medical services ("Non-Medical Services"):

a.     Membership limits: CCSI shall specifically limit the number of patients and/or families permitted to join the practice, in order to provide the enhanced services outlined in this agreement. If the physician'slimitedmembership panel is full, patients will be placed on a waiting list and contacted as soon as an opening becomes available.

b.     Anytime Access: Except in very rare situations, Patient shall have access to the Physician via instant messaging and/or video chat. The Patient shall also have direct telephone access to the Physician 24 hours per day, 7 days per week. Patient shall be given a phone number where Patient may reach the Physician directly. If your Physician is unavailable due to vacations, illnesses, continuing medical education conferences, or any other reason, another Physician or another clinical professional designated by CCSI will cover your Physician's calls and will respond to you as quickly as possible. Patient shall be given instructions as to how to contact such a healthcare provider. Such provider shall be available to Patient to the same extent as would the Physician; however, provider may be contacted through an answering service rather than through a direct phone line.

c.     Email Access: If you provided your Email above subject to the terms of the Agreement, Patient shall be given the Physician's email address to which non-urgent communications can be addressed. Such communications shall be dealt with by the Physician or staff member of the Practice in a timely manner. Patient understands and agrees that Email and the internet should never be used to access medical care in the event of an emergency or any situation that Patient could reasonably expect may develop into an emergency. Patient agrees that in such situations, when a Patient cannot speak to Physician immediately in person or by telephone, that Patient shall call 911 or the nearest emergency medical assistance provider, and follow the directions of emergency medical personnel.

d.     No Wait or Minimal Wait Appointments: Every effort shall be made to assure that Patient is seen by the Physician immediately upon arriving for a scheduled office visit or after only a minimal wait. If Physicians foresee a minimal wait time, Patient shall be contacted and advised of the projected wait time.

e.     Same Day or Next Day Appointments: When Patient calls the Physicians prior to noon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort shall be made to schedule an appointment with the Physician on the same day. If the Patient calls the Physicians after 12:00 (noon) on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort shall be made to schedule Patient's appointment no later than the following normal office day. CCSI will, nonetheless, make every reasonable effort to schedule an appointment for the Patient on the same day that the request is

f.      Home or Office Visits: Patient may request that the Physician see Patient in Patient's home or office, and in situations where the Physician considers such a visit reasonably necessary and appropriate, he will make every reasonable effort to comply with Patient's request.

g.     Inpatient visits: Physicians with CCSI will admit and manage the hospital care of Patients at HealthFloyd, providing direct patient care and coordinating all subspecialty care while admitted as Baptist permitted by the Hospital.

h.     Nursing Home Care: Physicians with CCSI are willing to manage nursing home care locally, as appropriate, and make nursing home rounds on Patients with appropriate notice and based on the regulations

i.      Visitors: Family members or friends temporarily visiting a Patient from out of town may, for a four-week period, take advantage of the services described in subparagraphs (a), (c), and (d) of this paragraph. Medical services rendered to Patient's visitors may be charged on a fee-for-service basis; however, fees shall not exceed $50 (fifty dollars) per visit for the services provided directly by Physicians.

j.      Executive Health Program: CCSI will provide similar services for executive teams and their families along with a comprehensive Executive Health Physical for the employee in the program.

6. Payment Terms:

a. In exchange for the program services, Patient agrees to pay CCSI*:

	Yearly	Quarterly	Monthly
Individual	$3,000.00	$750.00	$250.00
Individual + Spouse	$5,550.00	$1,375.00	$460.00
Family**	Family membership is customized with the office based on number of children and ages
Executive Health Program	Executive Health Program Fees determined based on needs of the company

*Fees may be paid monthly, quarterly, or yearly by direct deposit or automatic credit

**Age-appropriate dependent, please contact the office for details

b. If this Agreement is canceled by either party before the agreement termination date, then CCSI shall refund the Patient's prorated share of the original payment, less any amounts due for services already rendered.

 The parties have signed duplicate counterparts of this Agreement