DIRECT PRIMARY CARE MEMBERSHIP AGREEMENT
This DIRECT PRIMARY CARE MEMBERSHIP AGREEMENT (this "Membership Agreement") is agreed upon and effective on the Effective Date between with Scott Noorda D.O., PLLC, d/b/a Resolve Medical located at 640 East 700 South, Suite 201, Saint George, Utah 84790 (the "Clinic") and the Patient.
- Covered Services. "Covered Services" means the primary care services offered by the Clinic under this Membership Agreement. These Covered Services are listed below under the section entitled "Covered Services".
- Effective Date. "Effective Date" means the date upon which the Patient as completed each of the following: creates his or her Patient Portal, remits payment for membership with the Clinic, and signs this Membership Agreement.
- Membership Program. "Membership Program" means the Clinic's direct primary care program in which Patient enrolls.
- Monthly Anniversary. "Monthly Anniversary" means the monthly anniversary from the date of the Patient's first appointment.
- Monthly Membership Fee. "Monthly Membership Fee" means the monthly fee, which Patient agrees to pay, in the amount as calculated on www.pmhclinics.com/membership under "Build your plan" for St. George UT.
- Patient. "Patient" means those persons for whom the Clinic shall provide Covered Services, and who are signatories to or listed as a member in the Patient's account details in the Patient Portal.
- Patient Portal. "Patient Portal" means the online portal to which Patient is provided access by creating a username and password and on which Patient may manage his or her profile, payment method, request appointments, and other functions.
- TERMS AND CONDITIONS
- Membership. Patient hereby agrees to enroll as a member in the Clinic's Membership Program beginning on the Effective Date set forth above, and shall extend monthly thereafter. By being a member of the program, Patient shall be eligible to receive certain Covered Services. The Clinic may add or discontinue Covered Services at any time, as it may choose in its sole discretion. The Clinic shall provide at least thirty (30) days' advance written notice upon any change to the Covered Services.
- Monthly Membership Fees. Patient agrees to pay the Monthly Membership Fee in the amounts calculated on www.pmhclinics.com/membership under "Build your plan" for St. George UT, and charged by the Clinic to the Patient.
- Billing. Patient agrees the Clinic may automatically deduct payment from Patient's payment method, which is saved to the Patient Portal, for the Monthly Membership Fee. Monthly membership charges will begin on the day of the Patient's first appointment. Each subsequent Monthly Membership Fee will be charged on the Monthly Anniversary. Additional charges, for other services or goods, will be charged to the Patient's payment method at the time of service.
- Cancellation. The Clinic and Patient shall have the right to terminate the Membership Agreement without cause, upon prior written notice to the other party. If the Clinic terminates the Membership Agreement, cancellation will be effective thirty (30) days after the date of the notification. Upon receipt of notice of termination by the Patient, the Patient's membership will continue through the day prior to Patient's Monthly Anniversary. No refund or pro-rata billing will be applied for Patient terminations received mid-month. A Patient termination notice will take a minimum of five (5) business days to process. Termination notices received less than five (5) business days prior to the Patient's Monthly Anniversary will result in the Membership Program continuing through to the calendar day prior to Patient's next Monthly Anniversary.
- Effect of Cancellation. Upon cancellation of the Membership Agreement, the obligation of the Clinic, and the Clinic's staff, to provide Covered Services to the Patient immediately ceases.
- Reinstatement. In the event Patient terminates this Membership Agreement after the Effective Date hereof, Patient may restore his or her Membership Program if there is space on the Clinic's panel. If the Clinic panel is full, the Patient will be place on a waiting list and notified when a space is available. If a space becomes available, the Patient's Membership Agreement will be reinstated and a $129 reinstatement fee will be assessed at that time.
- Changes to Membership Fee Schedule. The Clinic may amend the Membership Fee Schedule at any time, as it may determine in its sole discretion, upon providing Patient at least thirty (30) days' advance written notice.
- Covered Services.
- Location, Hours of Operation, Access.
Same day appointments Monday through Thursday, some Fridays as posted, and Dr. Scott Noorda, or his staff, may be available by email and telephone during off office hours. Contact the Clinic by phone if there is an urgent problem.
The services provided under this Agreement will be provided at a site to be located at 640 East 700 South, Suite 201, Saint George, Utah 84790
Notwithstanding the hours of operation described above, the Clinic shall be closed for the following holidays: New Year's Day (January 1); President's Day (third Monday in February); Memorial Day (last Monday in May); Independence Day (July 4); Labor Day (first Monday in September); Thanksgiving (fourth Thursday in November); Day after Thanksgiving; Christmas Eve (December 24); Christmas (December 25). Clinic may also be closed on other days as scheduled to allow for vacation days for the Clinic staff.
The Clinic's physicians may, from time to time, due to vacations, sick days, and other similar situations, not be available to provide the Covered Services referred in this Membership Agreement. During such times, Patient's calls to the Clinic, or to the individual physicians, will be directed to a licensed medical provider who is "covering" for the physician during his absence. The Clinic will make every effort to arrange for coverage but cannot guarantee such coverage.
Nearly unlimited access (up to 99 encounters per month) to provide comprehensive primary care medicine via phone, Patient Portal messaging, and telemedicine. Not all conditions can be handled with these indirect methods and the Patient may be asked to make an in-person appointment.
- Primary care.
- Urgent care (Infections, gastrointestinal symptoms, rashes, common illnesses)
- Routine annual exams and screenings
- Lab draws
- Immunizations (as available from the Clinic)
- Pregnancy support & education
- Prescription management
- Health Maintenance and Prevention.
- Finger-stick blood test for glucose or HgbA1c
- Blood pressure, height, weight, body mass index and body fat composition.
Health Risk Assessment - Administered online or in paper version screens for:
- General health and well-being
- Health history including symptoms, conditions and family history
- Tobacco use, alcohol use and stress levels
Comprehensive Health Review (CHR) - For high risk individuals and individuals with chronic disease a CHR utilizing:
- 1:1 consultation with the onsite clinician to review assessment results, health history and risk appraisal, set goals and recommend strategies to achieve goals
- Disease Management.
For individuals with chronic diseases (Diabetes, COPD, Asthma, CHF, CAD, HTN, Depression, Low Back Pain):
- Work 1:1 with individuals to empower and educate them to improve their health and quality of life through self-management practices and adherence to a treatment plan that aligns with national clinical guidelines for their disease.
- Coaching, symptom monitoring, and disease education
- Limitations for Covered Services.
- Vaccine/medication administration (other than listed above, does NOT include price of medication unless otherwise stated)
- Access to cash pay discounts we are able to negotiate on the Patient's behalf from various third parties, such as imaging centers and laboratories
- Organization and review of historic and outside medical records
- Use of electronic medical records to help keep Patient's preventive services up to date and track referrals, labs, imaging reports until results are available
- Non-Covered Goods or Services.
- Anything not specifically listed as a Covered Service shall be a non-covered service
- Any health care services not performed on or within the premises of the Clinic including emergency room visits, hospital stays, specialist care, imaging and labs, reading of results, etc.
- Vaccines/medications not listed above (administration is included)
- Medical tests not performed in the office (as examples: actual "reading" of pap smears or biopsy results)
- Durable medical equipment (braces, splints, etc.)
- Massage therapy, acupuncture, counselling are billed separately for maximum flexibility
Patient understands and agrees that Patient is responsible for any charges for health care services performed outside of the Clinic, and any other health care goods and services described as excluded goods and services in this Membership Agreement. The Clinic 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.
- Third-Party Referrals and Preferred Rates. The Clinic may elect to coordinate with third party medical specialists to whom Patient is referred and may assist Patient in obtaining specialty care. Patient understands that fees paid under this Membership Agreement do not include and do not cover specialists' fees or fees due to any third-party medical professional. In the event the Clinic is able to negotiate a preferred rate on behalf of Patient for third party services (including, but not limited to advanced imaging, specialist visits, laboratory work, hospitalizations and other third-party medical services), and if such preferred rates require the Clinic to collect payment for services on behalf of the third party, such payments shall be paid by Patient to The Clinic in advance of Patient receiving such services. Any such payments on behalf of a Patient do not create any obligation on behalf of the Clinic other than to pay the third party provider. Patient is under no obligation to use such referrals.
- Electronic Communications. Patient acknowledges that communications with the Clinic using e-mail, facsimile, video chat, texting, instant messaging and cell phone (collectively, "Electronic Communications") are not guaranteed to be secure or confidential methods of communications. As such, Patient expressly waives the Clinic's obligation to guarantee confidentiality with respect to correspondence using such means of communication. Patient acknowledges that all such communications may become a part of their medical records. Patient authorizes the Clinic and its physicians to communicate with Patient by Electronic Communications regarding Patient's "protected health information" (PHI) (as that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulations).
If Patient does not receive a response to an Electronic Communication within one day, Patient must use another means of communication to contact the Clinic. The Clinic will not 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 technical failures, including, but not limited to, technical failures attributable to any internet service provider, power outages, failure of any electronic messaging software, or failure to properly address e-mail or text messages, failure of the Clinic's computers or computer network, or faulty telephone or cable data transmission, any interception of Electronic Communications by a third party; or your failure to comply with the guidelines regarding use of Electronic Communications as set forth in this paragraph.
- Non-Participation in Insurance. Patient acknowledges that the Clinic does not participate in any health insurance or HMO plans or panels and have opted out of Medicare. nEITHER THE PATIENT NOR the CLINIC HAVE MADE any representations whatsoever that any fees paid under this Membership Agreement are covered by any health insurance or other third party payment plans applicable to the Patient. The Patient shall retain full and complete responsibility for ALL FEES UNDER THIS MEMBERSHIP AGREEMENT. if patient is a medicare beneficiary, patient and the clinic must complete the private medicare opt-out contract provided in the enrollment flow and required as part of this MEMBERSHIP agreement.
- Insurance or Other Medical Coverage. Patient acknowledges and understands that this Membership Agreement is not an insurance plan, and not a substitute for health insurance or other health plan coverage (such as membership in an HMO). THE Clinic will not cover ANY health care services performed outside of the Clinic, OR any other health care goods and services described as excluded goods and services. Patient acknowledges that Clinic has advised that patient obtain or keep in full force such health insurance policy(ies)or plans that will cover Patient for general healthcare costs. Patient acknowledgeS that this Membership Agreement is not a contract that provides health insurance, and this Agreement is not intended to replace any existing or future health insurance or health plan coverage that Patient may carry.
- Indemnification. Patient agrees to indemnify and to hold the Clinic 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 Clinic as a result of the Patient's breach of any of Patient's obligations under this Agreement.
- Relationship of the Parties. Patient and the Clinic intend and agree that the Clinic's physician(s), in performing his/her duties under this Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and/or the United States Department of Labor, and the physician(s) shall have exclusive control of his/her work and the manner in which it is performed.
- 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 the Clinic 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 the Clinic or Patient.
- 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 the Clinic under this Membership Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and the Clinic reasonably believes in good faith that the change will have a substantial adverse effect on the Clinic's rights, obligations or operations associated with this Membership Agreement, then the Clinic 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 within ten (10) days after the effective date of change, then the Clinic may immediately terminate this Membership Agreement upon providing written notice to Patient.
- Governing Law. This Agreement and the rights and obligations of the Clinic and Patient hereunder shall be construed and enforced pursuant to the laws of the State of Utah.
- Severability. If for any reason any provision of this Membership 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 this Membership 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.
- Assignment/Binding Effect. This Membership Agreement shall be binding upon and shall inure to the benefit of both the Clinic 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 the Clinic.
- Reimbursement for Services Rendered. If this Membership Agreement is held to be invalid for any reason, and if the Clinic is therefore required to refund all or any portion of the monthly fees paid by Patient, Patient agrees to pay the Clinic an amount equal to the reasonable value of the Covered Services actually rendered to Patient during the period of time for which the refunded fees were paid.
- Amendment. The Clinic may unilaterally amend this Agreement as it deems necessary or to the extent required by federal, state, or local law or regulation ("Applicable Law") by notifying Patient 30 days advance of any such change. Any such changes are incorporated by reference into this Membership Agreement without the need for signature by the parties and are effective as of the date established by the Clinic, except that Patient shall initial any such change at the Clinic's request. Moreover, if Applicable Law requires this Membership Agreement to contain provisions that are not expressly set forth in this Membership Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Membership Agreement and shall be deemed a part of this Agreement as though they had been expressly set forth in this Agreement.
Medicare Private Agreement
Dr. Scott Noorda, D.O., NPI 1255624755, and Mr. Brandon Lewis, N.P., NPI: 1598246738, (collectively the "Providers") both of whom practice medicine at the Scott Noorda D.O., PLLC, d/b/a Resolve Medical located at 640 East 700 South, Suite 201, Saint George, Utah 84790 (the "Clinic") have not been excluded from Medicare under sections 1128, 1156 or 1892 of the Social Security Act.
The Patient accepts full responsibility for payment of charges for all services furnished by the Clinic and/or the Providers. "Patient" is defined as those persons who are signatories to or listed as a member in the Patient's account details with the Clinic.
Patient understands that Medicare limits do not apply to what the Clinic or Providers may charge for items or services furnished.
Patient agrees not to submit a claim to Medicare or to ask the Clinic or Providers to submit a claim to Medicare.
Patient understands that Medicare payment will not be made for any items or services furnished by the Clinic or Providers that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
Patient enters into this contract with the knowledge that the Patient has the right to obtain Medicare-covered items and services from a physician and/or practitioner who has not opted-out of Medicare, and Patient is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out.
The expected or known effective date and expected or known expiration date of the opt-out period is October 1, 2016 (effective date) and October 1, 2018 (expiration date) for Dr. Scott Noorda, D.O., and October 15, 2018 (effective date) and October 15, 2020 (expiration date) for Mr. Brandon Lewis. It is expected that the opt-out period for Dr. Scott Noorda, D.O., and the opt-out period for Mr. Brandon Lewis will each be automatically extended for an additional two-years and will continue to extend until otherwise notified by the respective practitioner.
Patient understand that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
This contract cannot be entered into by Patient, during a time when the Patient, requires emergency care services or urgent care services. (However, Providers may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 3044.28 of the Medicare Carriers Manual)
Patient may access a copy of this agreement at any time via the Patient Porter and is accessible before items or services are furnished to Patient under the terms of this agreement.
Clinic and Providers will also retain this agreement, via the Patient Portal, for the duration of the opt-out period.
Clinic and Providers will supply CMS with a copy of this contract upon request.
Patient, Clinic, and Providers understand that this Medicare private agreement remains in effect for two years and automatically renews for additional two-year periods until otherwise cancelled by the Providers or Patient. If the Providers reenter Medicare, Providers will notify Patient that this Medicare private agreement is cancelled immediately upon the effective date of the Providers reentry to Medicare.