CPA+ Membership Service Patient Agreement

In consideration of the mutual promises and undertakings set forth below, and for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, Physician agrees to provide Patient with the Program Services described in the Agreement on the terms and conditions set forth below.

1. Patient Information. Patient represents and warrants that his/her information set forth below is accurate and complete and agrees to promptly notify Physician of any changes.

2. Services. In consideration of the Membership Fee, Physician agrees to provide Patient with the following service amenities (the "Program Services").

(a) 24/7 after hours direct communication with Physician via Physician's cell phone through voice calls, text messaging, and Patient Portal access during hours when Physician is not providing services to other patients;

(b) Virtual visits utilizing FaceTime, Doxivity, or other similar media when deemed appropriate in the discretion of Physician;

(c) Prescription services, if appropriate. Patient specifically acknowledges that Physician will not provide, and the Program Services do not include hospital services, emergency services, surgery and/or related surgical services, radiology services, third-party services and/or laboratory services. Patient specifically acknowledges that the Program Services contemplated by this Agreement are those listed above in this Section 2 and nothing else. No part of this Agreement shall be construed as modifying, adding, or removing any other services including but not limited to: vaccinations, lab testing (CBC, urinalysis, Strep/Covid/Flu/RSV, glucose), hearing and vision screening, spirometry and peak flow asthma testing, ear removal, foreign body removal, simple laceration repair, fluoride varnish application in babies and toddlers, and circumcision of newborns. All such standard services will still be performed in the usual manner. Patient will still be required to come in for their routine Well Child Checkups. Patient will still maintain insurance, and Physician will continue to bill insurance and collect copay accordingly.

 

3. Membership Fees and Payments.

(a) Membership Fee. The fee for the Program Services is due and payable in full upon enrollment and shall be renewed by a periodic automated payment ("Membership Fee"). The amount of the fee varies based on the number of children in a household:

(b) Visit Fee. Patient will be charged an office visit fee per contact (the "Visit Fee"). 

(c) Refunds. If this Agreement is held to be invalid for any reason and if Physician is therefore required to refund all or any portion of the Membership Fee paid by the Patient, Patient agrees to pay Physician an amount equal to the reasonable value of the Program Services actually rendered to the Patient during the applicable period of time prior to when the refund is made.

(d) Fee Adjustment. Physician reserves the right to adjust Membership Fees annually. Any fee adjustments will be communicated to the Patient at least 60 days prior to the effective date of the change. Patients who do not agree to the revised fees may terminate the Agreement with no penalty within 30 days of receiving notice of the adjustment.

4. Health Care Services Excluded from Membership Fee. The Membership Fee and Visit Fee cover the cost of the Program Services; however, Membership Fee does not cover the cost of any health care services covered by health insurance. Physician makes no representations whatsoever that any fees paid under this Agreement are covered by Patient's health insurance or other third-party payment plans applicable to the Patient. Nothing in this Agreement supersedes or modifies the terms or conditions of any agreements related to your health insurance.

Patient acknowledges and understands that this Agreement is not an insurance plan and is not a substitute for health insurance or other health plan coverage. Patient acknowledges that Physician has advised Patient to obtain or keep in full force such health insurance policies or plans that will cover Patient for general healthcare costs. Further, Patient acknowledges that (i) the Program Services provided pursuant to this Agreement are not covered by insurance, Medicare, Medicaid and/or any other third-party payor, and (ii) Physician does not participate in any health insurance or HMO plans or panels and has opted out of Medicare and Medicaid. If Patient is eligible for Medicare or Medicaid, or during the term of this Agreement, becomes eligible for Medicare or Medicaid, then Patient, by signing the Agreement, acknowledges the Patient's understanding that Physician has opted out of Medicare and Medicaid, and as a result, neither Medicare nor Medicaid can be billed for any services performed for the Patient by Physician. Patient agrees to not bill Medicare or Medicaid for any reason or attempt reimbursement for any services.

6. Designated Physician. Program Services will be personally provided by Physician in accordance with the Agreement. Patient understands and acknowledges that Physician may not be available from time to time and may designate, on a temporary basis, during his unavailability, an equally qualified covering physician or other licensed professional who will be allowed access to Patient's medical history and course of care to attend to Patient's medical care needs. Additionally, Patient acknowledges that Physician will provide Program Services to patients and schedule appointments on a first-come, first-serve basis unless, in Physician's sole discretion, a patient presents with a medical condition that dictates otherwise.

7. Term and Termination. Unless earlier terminated as set forth below, the initial term of the Agreement shall be for one year, commencing on the Effective Date and terminating on the day following the first anniversary of the Effective Date (the "Initial Year"). Thereafter, the Agreement may be renewed by Patient for successive one-year periods (each, a "renewal Year"). Either party may decline to renew the agreement upon the written notification to the other party not less than 30 days prior to the expiration of the Initial Year or the Renewal Year, as applicable. The Agreement may be terminated as follows:

(a) Patient may terminate this Agreement at any time upon thirty (30) days prior written notice to Physician. Patient will not be entitled to a refund of Membership Fee or a portion thereof, except as provided in Section 7(c)(iii) below and Section 3.
(b) Patient may terminate this Agreement immediately upon their inability to travel to Physician for health reasons and/or the Patient moves to a new locality outside the area of the Physician and Physician.
(c) Physician may terminate this Agreement, at any time upon:
i. The occurrence of Patient's breach of the Agreement if such breach is not cured within 10 days;
ii. Patient having an outstanding balance of $100 or greater on their Physician account if not paid within 10 days after requested to do so; or
iii. 30 days prior written notice to Patient, with or without cause, related to the patient-physician relationship or any other non-contract related issue; in such case, Patient will be entitled to a refund of a prorated portion of the Membership Fee paid by the Patient for the year in which termination becomes effective.

(d) This Agreement automatically terminates upon the death or dissolution of the other Party.

8. Communications. Unless advised otherwise in writing, Patient authorizes Physician and Physician's staff and designees to communicate with Patient by Electronic Communication via Physician's patient portal regarding Patient's protected health information ("PHI" as defined in the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations) and its implementing regulations via Patient's cell phone and/or email address shown on this Agreement. Additionally, Patient will be able to communicate with Physician via email regarding test results or any other non-urgent medical issues. Email response will typically be within 24 hours and no later than within 2 business days. "Electronic Communication" includes but is not limited to email, text (SMS, MMS, Instant Messaging), and audio or video conference chat. Patient acknowledges and agrees that:

(a) Electronic Communication may not be a secure medium for sending or receiving PHI;
(b) Although Physician and Physician staff will make reasonable efforts to keep Electronic Communication with Patient confidential and secure, Patient understands that they cannot assure or guarantee the confidentiality of Electronic Communication;
(c) At the discretion of Physician, Electronic Communication may be made a part of Patient's permanent medical record.
(d) Patient will not use Electronic Communication for communications regarding emergency and/or urgent medical problems, or other time-sensitive issues. In the event of an emergency, or a situation in which the Patient could reasonably expect to develop into an emergency, Patient shall call 911 or proceed to the nearest emergency facility and follow the directions of emergency personnel.
(e) Patient will not use Electronic Communication for communications regarding sensitive personal information. In such cases Patient will call the designated phone number to communicate with Physician or his designee(s).
(f) If Patient does not receive a response to Patient's Electronic Communication message within the time frame specified in the Agreement (typically one business day, unless Patient indicates in the Electronic Communication that longer or shorter time-frame is desired), Patient will use another means of communication to contact Physician or appropriate representative; and
(g) Neither Physician nor any of his agents, consultants or representatives will be liable to Patient for any loss, damage, cost, injury or expense caused by, or resulting from:

(1) a delay in response to Patient due to technical failures, including but not limited to, technical failures attributable to internet service provider, power outages, failure of electronic messaging software, failure by Physician, or any of Physician's agents, consultants or representatives to properly address Electronic Communication messages, failure of computers or computer network, or faulty telephone or cable data transmission;
(2) any interception of Electronic Communication by a third party; or
(3) Patient's failure to comply with the guidelines regarding use of Electronic Communication set forth in this Section.

9. HIPAA Compliance. Physician commits to maintaining compliance with the Health Insurance Portability and Accountability Act (HIPAA) and all applicable laws governing patient privacy and data security. Patient records and communications shall be handled with strict confidentiality, except as required by law or authorized by the Patient in writing.

10. Notice. Any communication required or permitted to be sent under this Agreement (other than communications referenced in Section 8 relating to Patient's PHI) will be in writing and sent via facsimile, recognized overnight courier, or certified mail, return receipt requested, to the addresses set forth below:

IF TO PHYSICIAN: Trung D. Tran, MD
2020 W State Highway 114, Ste. 300 Grapevine, TX 76051 Fax #: (972) 331-4858

Any change in address will be communicated to the Parties in accordance with the provisions of this Section 10.

 

 

11. Amendment. The Agreement contains the entire agreement of the parties and supersedes all prior agreements and understandings between the Parties regarding the subject matter hereof. The Agreement may only be amended by a written agreement signed by the Parties. Notwithstanding the foregoing, Physician may amend this Agreement to the extent required by federal, state or local law, rule or regulation by sending Patient thirty (30) days advanced 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 Physician except that the Patient shall initial any such change at Physician's request.

12. Limitation of Liability. Physician shall not be held liable for delays, interruptions, or failures in providing services due to circumstances beyond their reasonable control, including but not limited to technical failures, Patient's noncompliance, or third-party service interruptions. Moreover, the Physician's total liability for any claims arising under this Agreement shall not exceed the lesser of: (1) the current annual fee amount for an individual under this agreement, or (2) the total Membership Fee actually paid by the Patient during the preceding 12 months.

Governing Law; Arbitration.

This Agreement shall be governed by the laws of the State of Texas. Any disputes arising under this Agreement shall first be subject to mediation. If mediation fails, disputes will be resolved exclusively through binding arbitration in Tarrant County, Texas, under the American Arbitration Association's rules. Each party shall bear its own legal fees and costs. The parties intentionally and voluntarily waive any right to a trial by jury in any matter arising out of this Agreement. Any dispute between Patient and Physician and/or Physician or their respective affiliates and agents arising or relating to this Agreement shall be resolved exclusively by binding arbitration in Tarrant County, Texas, before a neutral arbitrator, under the auspices of the American Arbitration Association, in accordance with the Expedited Rules and Procedures for Commercial Arbitration in effect at the time of arbitration. Any award rendered pursuant to such arbitration shall be final and binding upon the parties, and judgment upon the award rendered by the arbitrator may be entered in any court having jurisdiction over parties. Each party shall bear its own costs and attorneys' fees in connection with any such arbitration.

Entire Agreement.

This Agreement contains the entire agreement between the parties and supersedes all prior oral and/or written understandings and agreements regarding the subject matter of this Agreement.