BEAR FRUIT DIRECT PRIMARY CARE, PLLC
This Agreement, with an Effective Date of electronic signature is entered into between Bear Fruit Direct Primary Care, PLLC, (Practice, Us or We), and (Patient or You or Your)
The Practice, a medical provider, delivers primary care services in a membership based, direct primary care model (DPC) at 8221 Ranch Blvd, Suite 2, Little Rock, Arkansas, 72223. In exchange for certain fees, including a monthly periodic fee, the Practice, through Lillian West, MD, agrees to provide the Patient with Services described in and under the terms and conditions contained in this Agreement.
1. Services. “Services”, means the collection of medical and non-medical services which are provided to the Patient by the Practice under this Agreement and which are described in Appendix A (attached, and incorporated by reference.
2. Patient. “Patient” means the persons for whom the Practice shall provide care, and who have signed this agreement or are listed on the Patient Enrollment Form, which is attached as Appendix B, and incorporated by reference.
3. Term. This Agreement will last for one year, starting the date on which this Agreement is fully executed by the parties.
4. Renewal. The Agreement will automatically renew each year on the anniversary date of the agreement, unless either party gives the other 30 days written notice of non-renewal.
5. Termination. Either Party can terminate this Agreement by giving the other Party 30 days written notice of intent to terminate.
6. Payment. The Parties agree to the following policies and terms:
A) In exchange for the Services described in Appendix A, You agree to pay a periodic monthly fee (or Membership Fee) in the amount that appears in Appendix C (attached and incorporated into this Agreement), which shall be due on the 1st day of each month.
B) Patient also agrees to pay a one-time, non-refundable enrollment fee in the amount of 100$, and a monthly fee of 75$. Upon execution of this agreement the Patient shall pay both the enrollment fee and the Membership Fee (Membership Fee shall be prorated to the first of the month).
C) The Patient is responsible for the cost of any procedures, laboratory testing, specimen analysis and any other service or product not personally provided by the Practice staff and/or listed in Appendix A (Outside Services). If they are necessary, You shall be advised in advance of any such Outside Services, many of which the Practice shall make available on a cash basis through selected vendors at wholesale or close to wholesale price. Payment for such costs shall be due at the time of service. Alternatively, You have the right to obtain Outside Services at any place of your choosing, and submit the charges to insurance for possible reimbursement.
D) The Parties agree that the required method of payment shall be electronic transfer, through a debit or credit card, or automatic bank draft. The Patient shall sign an ACH agreement allowing such transfer.
7. Early Termination. If either Party cancels this Agreement before its termination date, We will refund any unused portion of the monthly fee on a per diem basis.
8. State Required Notice: A direct primary care agreement is not an insurance policy, and the select medical services as specified under a direct primary care agreement may not constitute the minimum essential health benefits under federal healthcare laws established by Pub. L. No. 111-148, as amended by Pub. L. No. 111-152, 26 and any amendments to, or regulations or guidance issued under, those statutes existing on January 1, 2017. Medical services provided under a direct primary care agreement may not be covered by or coordinated with your health insurance and you may be responsible for any payment for medical services not covered by health insurance under your insurer's statement of benefits policy.
9. Non-Participation in Insurance. Dr. West does not participate in any health insurance plan, HMO, Medicaid, Medicare or Tricare. As a result, neither you, nor we, may submit claims or seek reimbursement from any of them for any Services provided by Dr. West which are included under this Agreement. By electronic signature where indicated at the bottom of this clause, You acknowledge that you understand and agree to the above and further, You agree that you will not bill or attempt to obtain to reimbursement from these third party payors for Services provided under this Agreement.
10. Medicare. By placing your electronic signature at the bottom of this clause 10, of the Agreement, you acknowledge Your understanding that the Dr. Lillian West has opted out of Medicare, and as a result, Medicare cannot be billed for any services she personally performs for You. You agree not to bill Medicare or attempt to obtain Medicare reimbursement for any such services. If You are eligible for Medicare, or become eligible during the term of this Agreement, then You will execute the Medicare Opt Out and Waiver Agreement attached as Appendix D and incorporated by reference. The You agree to sign and renew the Medicare Opt Out and Waiver Agreement as required by law thereafter.
11. Communications. The Practice endeavors to provide Patients with the convenience of a wide variety of electronic communication options. And although We are careful to comply with patient confidentiality requirements, and make every attempt to protect Your privacy, communications by e-mail, facsimile, video chat, cell phone, and other electronic means, can never be absolutely guaranteed to be secure or confidential methods of communications. By placing your initials at the end of this Clause, You understand and acknowledge the above and You agree that by initiating the clause, and participating in the above means of communication, you expressly waive any guarantee of absolute confidentiality with respect to their use. You further understand that participation in the above means of communication is not a condition of receiving care from this Practice, that you are not required to agree to this clause, that you can refuse to above communication methods by withholding your initials from the bottom of this clause 10, and that You always have the option to decline any particular means of communication.
12. Email. 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). By providing cell phone number on Appendix B and circling “YES” on the corresponding consent question, patient consents to text message communication containing PHI through the number provided. Patient further acknowledges that:
E-mail is not necessarily a secure method of sending or receiving PHI, and there is always a possibility that a third party may gain access;
Although the Practice and its staff shall make all reasonable efforts to keep e-mail and text communications confidential and secure, We cannot can assure or guarantee the absolute confidentiality of these communications;
You also understand and agree that e-mail is not appropriate means of communication in an emergency, for dealing with time-sensitive issues, or for disclosing sensitive information. In an emergency, or a situation in which could reasonably be expected to develop into an emergency, You understand and agree to call 911 or go to the nearest personnel.
You agree that email and text messaging are not appropriate means of communication in situations requiring a quick response. You further agree that if you use these methods, and do not receive a timely response you will contact the Physician or other staff by telephone. By placing your initials where indicated at the end of this clause 11, you verify that you understand and agree to its statements and terms.
13. Dispute Resolution. Each Party agrees not to make any inaccurate, or untrue and disparaging statements, oral, written, or electronic, about the other. We strive to deliver only the best of 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 and We are committed to resolving all Patient concerns.
Therefore, in the event that 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. Rather, the Parties agree to engage in the following process:
Member shall first discuss any complaints concerns or issues with Dr. West;
Dr. West shall respond to each of Member's issues and complaints;
If, after such response, Member remains dissatisfied, the Parties shall enter into discussion and attempt to reach a mutually acceptable solution.
14. Fee Adjustments and Service Offerings. In the event that the Practice finds it necessary to increase or adjust monthly fees before the termination of the Agreement, Practice shall give Patients 60 days written notice of any adjustment and if Patient does not consent to the modification, Patient shall terminate the Agreement in writing prior to the next scheduled monthly payment. The same procedure shall apply in the event that the Practice either expands or eliminates certain Services contained in Appendix A. In any event, adjustments in fees and/or Service offerings shall be made not more frequently than annually.
15. Technical Failure. Neither the Practice, nor the Physician will be liable for any loss, injury, or expense arising from a delay in responding to Patient, when that delay is caused by technical failure. Examples of technical failures (i) failures caused by an internet service provider, (ii) power outages, (iii) failure of electronic messaging software, or e-mail provider (iv) failure of the Practice’s computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of e-mail communications by a third party which is unauthorized by the Practice; or (v) Patient failure to comply with the guidelines for use of e-mail described in this Agreement.
16. Physician Absence. From time to time, due to vacations, illness, or personal emergency, the Physician may be temporarily unavailable. When times of absences are known in advance, the Practice shall give notice to 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, 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.
17. Technical Failure. Neither the Practice, nor the Physician will be liable for any loss, injury, or expense arising from a delay in responding to Patient, when that delay is caused by technical failure. Examples of technical failures (i) failures caused by an internet service provider, (ii) power outages, (iii) failure of electronic messaging software, or e-mail provider (iv) failure of the Practice’s computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of e-mail communications by a third party which is unauthorized by the Practice; or (v) Patient failure to comply with the guidelines for use of e-mail described in this Agreement.
17. Change of Law. If there is a change of any relevant law, regulation or rule, federal, state or local, which affects the terms of this Agreement, the parties agree to amend this Agreement to comply with the law.
18. Severability. If any part of this Agreement is considered legally invalid or unenforceable by a court of competent jurisdiction, such part will be amended to the extent necessary to be enforceable. The remainder of the contract will stay in force as originally written.
19. Reimbursement for services rendered. If this Agreement is held to be invalid for any reason, and the Practice is required to refund fees paid by You, You agree to pay the Practice an amount equal to the fair market value of the medical services You received during the time period for which the refunded fees were paid.
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. Neither this Agreement, nor any rights provided under it, may be assigned or transferred to any third party by the Patient.
22. Legal Significance. You acknowledge that this Agreement is a legal document and gives the parties certain rights and responsibilities. You also acknowledge that You have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.
23. Miscellaneous. This Agreement shall be construed without regard to any rules requiring that it be construed against the party who drafted the Agreement. The captions in this Agreement are only for the sake of convenience and have no legal meaning.
24. Entire Agreement. This Agreement contains the entire agreement between the parties and replaces any earlier understandings and agreements whether they are written or oral.
25. No Waiver. In order to allow for the flexibility of certain terms of the Agreement, each party agrees that they may choose to delay or not to enforce the other party’s requirement or duty under this agreement (for example notice periods, payment terms, etc.). Doing so will not constitute a waiver of that duty or responsibility. The party will have the right to enforce such terms again at any time.
26. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Arkansas. All disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for Little Rock, AR.
27. Notice. The Parties may affect notice required under Section 14, above, electronically, by sending notice to the prospective party’s most recently provided email address or through first class US Mail. All other required notices must be sent through first class US Mail, to the address of the Practice at the address first written above or to the Patient at the address appearing in Appendix B.
The parties may have executed this Agreement on the dates set forth below, but its effective date is the date written above and identified as the Effective Date.
The Physician is not a pain specialist, does not prescribe scheduled drugs through any telemedicine or virtual care platform.
Medical Services.* Medical Services provided in this Agreement are those Services that are consistent with Physician’s training and experience, and are usual and customary for an internal medicine physician to provide, and as deemed appropriate under the circumstances, at the sole discretion of the Physician. The Patient is responsible for all costs associated with any medications, laboratory testing, and specimen analysis associated with these Services. The Medical Services provided under this Agreement include the following*:
Acute and Non-acute Virtual and or Phone Visits
Chronic Care Management (Asthma, COPD, Diabetes, Hypertension, High Cholesterol, etc)
Annual Physical Exam
* Patient is responsible for the costs of all imaging, testing, labs, specimen analysis, or other procedures. Patient will be advised in advance and most such services will be offered at highly discounted cash pay rates through select vendors.
** Does not include the cost of any necessary pathology.
Non-Medical, Personalized Services. The Practice shall also provide Patient with the following non-medical services, which are complementary to our members in the course of care:
After Hours Access. The Practice shall endeavor to provide direct telephone access to the Physician for guidance in regard to urgent concerns that arise unexpectedly after office hours. Video chat and text messaging may be used when the Physician and Patient agree that it is appropriate.
E-Mail Access. Patient shall be given the Physician’s e-mail address to which non-urgent communications can be addressed. Such communications shall be dealt with by the Physician or staff member in a timely manner. Patient understands and agrees that email and the internet should never be used to access medical care in urgent situations or in the event of an emergency, or a situation that could reasonably develop into an emergency. Patient agrees that in this situation, when s/he cannot speak to the Physician immediately in person or by telephone, to call 911 or go to the nearest emergency medical assistance provider, and follow the directions of emergency medical personnel.
No Wait or Minimal Wait Appointments. All reasonable effort shall be made to assure that Patient is evaluated virtually by the Physician at the scheduled appointment. If the Physician foresees a minimal wait time, Patient shall be contacted and advised of the projected wait time.
Same Day/Next Day Appointments. When a Patient with an contacts the Practice prior to noon on a regular office day, to request a same-day appointment, every reasonable effort shall be made to schedule the Patient for that same day. In any event, and regardless of when request is made, the Practice shall always make every reasonable effort to schedule same day or next day appointments upon Patient request.
Specialists Coordination. Physician shall coordinate with Patient’s medical specialists to assure continuity of care, and if necessary, shall assist in obtaining a referral for specialty care. Patient understands that fees paid under this Agreement do not include specialist’s fees or fees due to any medical professional other than the Practice Physician.