The Practice has offices at 5 locations in Arizona, Nevada, California, and Oregon. (for locations, please visit the PMG website at www.pmgcare.com for locations & Hours) this contract applies to all locations on the website, with appointments at each location requiring prior established and confirmed visits. NO Drop-In appointments without confirmed appointments. PMG will provide ongoing primary care & Psychiatric services to its patients/members in a Direct Primary & Psychiatric Care practice model (DPC & DPSYCHC & DPSYCHC). In exchange for specific periodic fees, the Practice agrees to provide the Patient with certain Services under the terms and conditions contained in this Agreement.
State Required Notice
MDVIP365 LLC, DBA Priority Medical Group, is not an insurance company, and this Direct Primary & Psychiatric Care (DPC & DPSYCHC) Agreement (Agreement) is not an insurance policy. Your participation in MDVIP365 LLC DBA Priority Medical Group and your subscription to any of its documents should not be considered a health insurance policy. Regardless of your membership in the DPC & DPSYCHC Practice, you are always responsible for paying any additional healthcare expenses you may incur. If you have health insurance, it may include, at no extra charge, some of the preventive services contained in this Agreement. We may not bill your insurance for services provided to you under this Agreement. Therefore, we will not bill any insurance plan or prepare invoices for patients to submit for reimbursement.
Definitions
1. Services. In this Agreement, “Services” means the collection of medical and non-medical services provided to the Patient by the Practice under this Agreement, described in Appendix A, which is attached and incorporated into this Agreement
2. The Patient. In this Agreement, “Patient,” “Member,” “You,” or “Yours” means the person/s for whom the Licensed Provider shall provide care, who has signed this Agreement and/or whose name/s appear on the Patient Enrollment form, which is attached as Appendix B, and incorporated by reference.
Agreement Term.
3. This Agreement will last one year, starting when both parties execute it.
4. Renewal. The Agreement will automatically renew each year on its anniversary date unless either party cancels it by giving 30 days written notice of intent to terminate.
5. Termination.
Either party can end this Agreement by giving the other 30 days’ written notice, intending to terminate. The practice can give notice through first-class US mail or by email to the address provided by the Party to be notified. Patients must give notice through first-class US mail to the practice address written above. The Practice may not terminate this agreement based on discriminatory factors such as gender, race, and religion, nor solely on the patient's health status.
6. Payment.
a.In exchange for the provision of the ongoing Services described in Appendix A, the Patient agrees to pay the Practice a monthly periodic fee in the amount that appears in Appendix C (attached and incorporated by reference). Such periodic fees shall be due and payable on the first day of each month.
In addition, upon executing this Agreement, the Patient agrees to pay a one-time, non-refundable enrollment fee as described in Appendix C and the above-described periodic fee.
c.The Parties agree that the required payment method, such as a debit or credit card or automatic bank draft, shall be electronic. No personal or bank checks will be honored at any time.
d.The Patient is responsible for all costs/fees associated with procedures, medical imaging (radiology), laboratory testing, specimen analysis, supplies, medications, including vaccinations, and any other service personally or not personally provided by the Practice staff and/or not listed in Appendix A. The patient can use their health insurance for third-party vendor services if applicable and accepted by the third-party vendors.
e. The patient shall be advised before treatment of additional fees or costs and may choose to obtain such optional services elsewhere. However, if the patient elects to receive such services from the Practice, additional fees shall be due at the time of service and billed at the same time as the monthly periodic fee. Please refer to Appendix A for a further cost structure.
7. Payment.
a.In exchange for the provision of the ongoing Services described in Appendix A, the Patient agrees to pay the Practice a monthly periodic fee in the amount that appears in Appendix C (attached and incorporated by reference). Such periodic fees shall be due and payable on the first day of each month.
b. In addition, upon executing this Agreement, the Patient agrees to pay a one-time, non-refundable enrollment fee as described in Appendix C and the above-described periodic fee.
c. The Parties agree that the required payment method, such as a debit or credit card or automatic bank draft, shall be electronic. No personal or bank checks will be honored at any time.
8. Payment.
a. In exchange for the provision of the ongoing Services described in Appendix A, the Patient agrees to pay the Practice a monthly periodic fee in the amount that appears in Appendix C (attached and incorporated by reference). Such periodic fees shall be due and payable on the first day of each month.
b. In addition, upon executing this Agreement, the Patient agrees to pay a one-time, non-refundable enrollment fee as described in Appendix C and the above-described periodic fee.
c. The Parties agree that the required payment method, such as a debit or credit card or automatic bank draft, shall be electronic. No personal or bank checks will be honored at any time.
d. The Patient is responsible for all costs/fees associated with procedures, medical imaging (radiology), laboratory testing, specimen analysis, supplies, medications, including vaccinations, and any other service personally or not personally provided by the Practice staff and/or not listed in Appendix A. The patient can use their health insurance for third-party vendor services if applicable and accepted by the third-party vendors.
e. The patient shall be advised of additional fees or costs before treatment and may choose to obtain such optional services elsewhere. However, if the patient elects to receive such services from the Practice, additional fees shall be due at the time of service and billed at the same time as the monthly periodic fee. Please refer to Appendix A for a further cost structure.
9. Early Termination.
a. If the Practice cancels this Agreement before its termination date, we will refund the unused portion of the Patient’s monthly fee on a per diem basis.
b. If the Patient cancels this Agreement before its termination date, the Practice will review and settle the Patient’s account as follows:
i. The practice will refund the unused portion of the Patient’s fees on a per diem basis or
ii. if the fair market value of the Services received during the term, but before the Patient cancels the Agreement, is more than the total amount paid in membership fees during the term, the Patient agrees to reimburse the Practice in the amount of the difference. The Parties agree that the fair market value of Services is equal to the Practice’s usual and customary fee-for-service charges for the services received. A copy of these fees is available on request
1. Medicare. By placing YOUR SIGNATURE BELOW INDICATES YOU UNDERSTAND this clause in the space provided, you acknowledge that You understand and agree that the Licensed Provider WILL NEVER bill or submit claims to Medicare and that Medicare cannot be billed for any services personally performed or provided to You by the Licensed Provider or the Practice. You agree not to directly or indirectly submit charges to Medicare or attempt to obtain Medicare reimbursement for any such services. If You are eligible for Medicare or become eligible during the term of In this Agreement, you agree to sign the Medicare Opt Out and Waiver Agreement attached as Appendix D. You further agree to sign and renew the Medicare Opt Out and Waiver Agreement every two years or as required by law.
2. YOUR SIGNATURE BELOW INDICATES YOU UNDERSTAND This Is Not Health Insurance. Your initials on this clause of the Agreement acknowledge Your understanding that this Agreement is not an insurance plan or a substitute for health insurance nor a replacement for any existing health insurance or health plan coverage that You may carry. This Agreement does not include hospital services or any services not personally provided by the Practice or its staff. You acknowledge that We have advised You to obtain or continue, in full force, health insurance that will cover You for healthcare services not personally delivered by the Practice, including but not limited to specialist care and for hospitalizations and catastrophic medical events.
3. No Submission of Claims to Third Parties. Neither the Practice nor its Staff participates in health insurance or HMO plans. Furthermore, as a DPC & DPSYCHC practice, we may not submit a claim for payment to any third-party payor (such as insurance plans) for any services We provide to You. We cannot provide you with a receipt or invoice reflecting charges for individual services because we are not a fee-for-service model. You are responsible for ascertaining whether any fees paid under this Agreement are reimbursable through an HSA, FSA or other spending account.
In this Agreement, you agree to sign the Medicare Opt Out and Waiver Agreement attached as Appendix D. You further agree to sign and renew the Medicare Opt Out and Waiver Agreement every two years or as required by law.
4. YOUR SIGNATURE BELOW INDICATES YOU UNDERSTAND Communications. The Practice endeavors to provide Patients with the convenience of various electronic communication options. Although We are careful to comply with patient confidentiality requirements and make every attempt to protect Your privacy, communications by email, facsimile, video chat, cell phone, texting, and other electronic means can never be guaranteed to be secure or confidential methods of communication. You understand and acknowledge the above by placing your initials on this Clause. You agree that by initiating the clause and participating in the above means of communication, you waive any guarantee of absolute confidentiality concerning their use. You further understand that participation in the above means of communication is not a condition of membership in this Practice, that you are not required to initial this clause, and that you can decline any means of communication.
5. Email and Text Usage. By providing an e-mail address on the attached Appendix B, the Patient authorizes the Practice and its staff to communicate with him/her by e-mail regarding the Patient’s “protected health information” (PHI).1 By providing the cell phone number in Appendix B and clicking next to the “YES” on the corresponding consent question, the patient consents to text message communication containing PHI through the number provided. The patient further acknowledges that:
a. Email and text messages are not necessarily secure methods of sending or receiving PHI, and there is always a possibility that a third party may gain access.
b. Although the Practice and its staff shall make all reasonable efforts to keep email and text communications confidential and secure, we cannot assure or guarantee the absolute confidentiality of these communications.
c. You also understand and agree that email and text messaging are inappropriate means of communication in an emergency, when dealing with time-sensitive issues, or when disclosing sensitive information.
d. In an emergency or a situation that could reasonably be expected to develop into an emergency, you understand and agree to call 911 or go to the nearest emergency room and follow the directions of emergency personnel.
e. You agree that email and text messaging are inappropriate for communication in situations requiring a quick response. You further agree that if you use these methods and do not receive a
1. Defined in the Health Insurance Portability and Accountability Act (HIPAA) 1996 and its implementing regulations.
Timely response: you will contact the Licensed Provider or other staff by telephone. By placing your initials indicated at the end of this clause, you verify that you understand and agree to its statements and terms. YOUR SIGNATURE BELOW INDICATES YOU UNDERSTAND THE TERMS AND CONDITIONS OF THIS PARAGRAPH.
6. Technical Failure. Neither the Practice nor its staff shall be liable for any loss, injury, or expense arising from a delay in responding to the Patient when that delay is caused by technical failure. Examples of technical failures:
i. failures caused by an internet or cell phone service provider;
ii power outages.
iii. Failure of electronic messaging software or e-mail provider.
iv. Failure of the Practice’s computers, computer network, or faulty telephone or cable data transmission.
v. Any interception of e-mail communications by a third party that is unauthorized by the Practice or
vi. Patient’s failure to comply with e-mail or text messaging guidelines, as described in this Agreement.
7. Licensed Provider Absence. From time to time, due to vacations, illness, or personal emergencies, the Licensed Provider may be temporarily unavailable. When times of absences are known in advance, the Practice shall notify patients so that they can schedule non-urgent care accordingly. During unexpected absences, Patients with scheduled appointments shall be rescheduled at the Patient’s convenience. In the case of an acute illness requiring immediate attention, the Patient should proceed to an urgent care or other suitable facility for care. Charges from Urgent Care and any other outside provider are not included under this agreement and are the Patient’s responsibility.
In a timely response, you will contact the Licensed Provider or other staff by telephone. By your SIGNATURE BELOW, YOU UNDERSTAND indicated at the end of this clause, you verify that you understand and agree to its statements and terms.
8. Technical Failure. Neither the Practice nor its staff shall be liable for any loss, injury, or expense arising from a delay in responding to the Patient when that delay is caused by technical failure. Examples of technical failures:
vii. Failures caused by an internet or cell phone service provider.
viii. Power outages.
ix. Failure of electronic messaging software or e-mail provider.
x. Failure of the Practice’s computers, computer network, or faulty telephone or cable data transmission.
xi.Any interception of e-mail communications by a third party that is unauthorized by the Practice or
xii. Patient’s failure to comply with e-mail or text messaging guidelines, as described in this Agreement.
9. Licensed Provider Absence. From time to time, due to vacations, illness, or personal emergency, the Licensed Provider may be temporarily unavailable. When times of absences are known in advance, the Practice shall notify patients so that they can schedule non-urgent care accordingly. During unexpected absences, Patients with scheduled appointments shall be rescheduled at the Patient’s convenience. In the case of an acute illness requiring immediate attention, the Patient should proceed to an urgent care or other suitable facility for care. Charges from Urgent Care and any other outside provider are not included under this agreement and are the Patient’s responsibility.
10. Dispute Resolution. Each Party agrees not to make any inaccurate, untrue, or disparaging statements, oral, written, or electronic, about the other. We strive to deliver the best-personalized patient care to every member, but occasionally, misunderstandings arise. We welcome sincere and open dialogue with our members, especially if we fail to meet expectations. We are committed to resolving all patient concerns.
Therefore, if a member is dissatisfied with or has concerns about any staff member, service, treatment, or experience arising from their membership in this Practice, the Member and the Practice agree to refrain from making, posting, or causing to be posted on the internet or any social media, any untrue, unconfirmed, inaccurate, disparaging comments about the other. Instead, the Parties agree to engage in the following process:
a. Member shall first discuss any complaints, concerns, or issues with their Licensed Provider.
b. Their respective Licensed Providers shall respond to each Member's issues and complaints.
c. Suppose the Member remains dissatisfied after such a response. In that case, the Patient and Kirk Tjalas FNP, PMHNP CEO and President of PMG, shall discuss the matter and attempt to reach a mutually acceptable solution
d. If no resolution is found, a mutually accepted third party will be invited to arbitrate on behalf of both parties, and both parties will take the arbitrator's decision as being in good faith and final.
11. Fee Adjustments. Suppose the Practice finds it necessary to increase or adjust monthly fees before the termination of the Agreement. In that case, the Practice shall give the Patient 30 days’ written notice of any adjustment. If the patient does not consent to the modification, the Patient shall terminate the Agreement in writing before the next scheduled monthly payment. Practice and Patient may give notice through first-class US mail or by email to the address provided by the Party to be notified.
12. Change of Law. If any relevant law, regulation, or rule, federal, state, or local, changes affect the terms of this Agreement, the parties agree to amend this Agreement to comply with the law.
13. Severability. Suppose a court of competent jurisdiction considers any part of this Agreement legally invalid or unenforceable. In that case, that part will be amended to the extent necessary to be enforceable, and the remainder of the Agreement will stay in force as originally written.
14. Amendment. Except as provided within, no amendment of this Agreement shall be binding on a party unless it is in writing and signed by all the parties.
15. Assignment. The Patient may not assign this Agreement or any rights provided to any third party.
16. Legal Significance. The Patient understands and agrees that this Agreement is a legal document and gives the parties certain rights and responsibilities. The Patient further attests that
a. s/he is suffering no medical emergency.
b. s/he has had reasonable time to seek legal advice regarding this Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of the Agreement.
17.Miscellaneous. This Agreement shall be construed without regard to any rules requiring it be construed against the party who drafted it. The captions in this Agreement are only for convenience and have no legal meaning.
18. Affects the terms of this Agreement, the parties agree to amend this Agreement to comply with the law in the states listed on PMG’s website found at www.pmgcare.com
19. Severability. Suppose a court of competent jurisdiction considers any part of this Agreement legally invalid or unenforceable. In that case, that part will be amended to the extent necessary to be enforceable, and the remainder of the Agreement will stay in force as originally written.
20. Amendment. Except as provided within, no amendment of this Agreement shall be binding on a party unless it is in writing and signed by all the parties.
21. Assignment. The Patient may not assign this Agreement or any rights provided to any third party.
22. Legal Significance. The Patient understands and agrees that this Agreement is a legal document and gives the parties certain rights and responsibilities. The Patient further attests that
a. s/he is suffering no medical emergency.
b.s/he has had reasonable time to seek legal advice regarding this Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of the Agreement.
23. Miscellaneous. This Agreement shall be construed without regard to any rules requiring it be construed against the party who drafted it. The captions in this Agreement are only for convenience and have no legal meaning.
24. Entire Agreement. This Agreement contains the whole agreement between the parties and replaces any earlier understandings and agreements, whether written or oral.
25.No Waiver. Either party may delay, excuse, or not enforce the other Party's duty or responsibility (under this Agreement). Doing so will not constitute a waiver of the right to enforce such duty or responsibility in the future. The party will have the right to enforce their rights under this Agreement again at any time.
26. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Arizona without regard to rules of conflicts of laws. All disputes arising from this Agreement shall be settled in the court of proper venue and jurisdiction For Pima County, Arizona.
27. Notice. All written notices, except those required under paragraph 17, shall be sent by first-class U.S. mail to the Practice at the address first written above and to the Patient at the address appearing in Appendix B.
The Parties may have signed duplicate counterparts of this Agreement on the date first written above