Important Notice: Medicaid Insurance Not Accepted

We value your health and well-being, and we want to ensure transparency in our services. As per the Kentucky state law, we regret to inform you that we are unable to accept Medicaid insurance at this time.

We understand the significance of Medicaid coverage, and we empathize with the challenges this may present. However, due to legal restrictions, we are unable to process Medicaid claims or provide services covered by this insurance.

We understand that some individuals may consider paying out of pocket for our services, but unfortunately, under Kentucky state law, we cannot provide Direct Primary Care (DPC) services to anyone with Medicaid insurance, even if they choose to pay privately.

Your health is our priority, and we remain devoted to serving the Kentucky community. Thank you for your understanding, and we sincerely apologize for any inconvenience this may cause.

Rate each of the following symptoms based upon your typical health profile for the past 14 days.

Point Scale: 

0 - Never or almost never have the symptom	3 - Frequently have it, the effect is not severe
1 - Occasionally have it, the effect is not severe	4 - Frequently have it, the effect is severe
2 - Occasionally have it, the effect is severe

I am being treated at Future Hope Primary Care (FHPC) a division of Future Hope Health Group (FHHG) and I consent to all medical and surgical care, examinations, and tests determined by my provider that are necessary for me.  Though I expect the care given will meet customary standards, I understand there are no guarantees concerning the results of my care.  I also understand that if I do not follow my provider’s recommendations as they may relate to my health, the provider and this office will not be responsible for any injuries or damages that are the result of my non-compliance.  I understand that if an employee or individual associated with Future Hope Health Group is exposed to my blood or body fluids, I will be tested for hepatitis viruses and the HIV virus.  I also understand that I will receive education related to this testing and I will not be charged for testing and education related to the exposure.

Consent to Use of Information
Electronic Health Records— I understand that FHHG) utilizes electronic health records (EHR) and I consent to share my information with their EHR system.  I agree that (with consent when indicated) records may be shared electronically.  I consent to the inclusion of the EHR of sensitive diagnoses and related information such as HIV?AIDS status, sexually transmitted diseases, genetic information, and mental health and substance abuse, etc.  The EHR will be accessible by FHHG credentialed practitioners as well as other individuals approved to access them for purposes related to treatment, payment, health care operations, and /or other purposes permitted by federal and state laws.  FHHG has implemented administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality and integrity of my medical information as required by HIPAA.
   Use and Disclosure of Information— I agree that FHHG may use and disclose my health information for a range of purposes including treatment, eligibility verification, state and federal government programs, Worker’s Compensation programs, pre-authorizations for procedures, quality of care assessment & improvement activities, evaluating the performance of employees, conducting medical training & educational programs, medical reviews/audits, compliance with legal, regulatory & accreditation requirements of public health & health oversight services when required.
   As per the Membership Agreement, I understand that information will not be disclosed to other providers/ hospitals/ health departments without written consent by the patient or their guardian.  

Acknowledgment of Receipt of “Notice of Privacy Practices”
I acknowledge that I have received or been offered a copy of FHHG’s “Notice of Privacy Practices” (HIPPAA) which provides information on how the office may use or disclose protected health information (PHI) for purposes of treatment, payment, or health care operations.

Financial Responsibility
   I acknowledge that I have read and understood the financial agreement as described in the FHPC Membership Agreement. 
   I understand that I am financially responsible for the payment of all charges incurred which are not covered by my Membership Agreement.  We will make every effort to explain those to you prior to services rendered.  Payment will be taken at the time of service.
   I understand that supplements, medications, or other suggested treatment modalities not explicitly outlined in the membership agreement are my financial responsibility.
   I understand that FHHG is not responsible for the fees charged by any outside vendor such as (but not limited to) a lab, hospital, imaging facility, or specialist.  
   I understand that FHPC does NOT have agreements with insurance companies and will not file claims on my behalf.   

Personal Valuables
I understand that FHHG does not accept responsibility for any lost, stolen, or damaged personal items while I am at the office.

Cancellation and No-Show Policy
In order to meet the needs of all our patients for timely appointments, our office requires a minimum of 72 hours to cancel/change an appointment.  Your appointment time is reserved for YOU.  If you don’t keep that time, we can’t meet your needs or those of our other members.  
If you arrive too late to both see you and finish an appointment in a timely manner, you may be asked to reschedule your appointment.  We don’t want our providers to try to rush through an appointment or to make our next member wait.
We reserve the right to charge a fee for a no-show or late cancellation/re-scheduling of an appointment.

 

 

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. 

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information that is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI, and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, or text. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in the normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
6. Your confidential information will not be used for the purposes of marketing or advertising products, goods, or services.
7. We agree to provide patients with access to their records in accordance with state and federal laws.
8. We may change, add, delete, or modify any of these provisions to better serve the needs of both the practice and the patient.
9. You have the right to request restrictions in the use of your protected health information and to request changes in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

 I, the undersigned, do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA Information and Consent Form and any subsequent changes in office policy.   I understand that this consent shall remain in force from this time forward.

1. Patient-Clinician Relationship
By your signature, you acknowledge that you are voluntarily becoming a patient of Future Hope Primary Care (referred to as FHPC for the rest of this agreement) and its medical group of affiliated clinicians.  As an FHPC  patient, those services described in Section 2 below will be made available to you pursuant to the terms of this Membership Agreement.

2. Future Hope Primary Care Services
Health Care Services:  As a patient, you are eligible to receive a set of primary care, preventive care, and urgent care services as offered by our providers.  You are also eligible to receive 24/7 emergency phone care.  Email communication is available and will be answered during office hours.  Acute care appointments will be available the same or the next day (… unforeseen circumstances).  Preventive and chronic care appointments will be scheduled in a timely manner.  During the term of this Agreement, additional Health Care Services may be provided by FHPC and may be subject to change from time to time.  
If you have a preexisting medical condition, please contact us first to learn how you may benefit from Future Hope Primary Care’s services.  Pre-existing medical conditions do not disqualify you from enrolling in FHPC’s service. 
By signing this document, you are acknowledging that you understand the philosophy of FHPC and how it may be different from other allopathic primary care providers.
By entering into this Membership Agreement, you acknowledge the FHPC does not provide health insurance coverage and that this is not a contract for insurance.  
FHPC provides only the Health Care Services specifically described herein and additional costs may be incurred for laboratory, medical imaging, surgery, specialist care, emergency department visits, and hospitalization required outside of FHPC’s services.  You acknowledge that FHPC has no control over the charges for those services or insurance coverage that may or may not be in effect for those services.  (Please keep in mind that FHPC is not contracted with any insurance companies and that may affect an insurer's coverage for outside services.)
FHPC encourages you to combine FHPC membership with appropriate health insurance coverage.

 3. Fees and Payment
FHPC charges the Comprehensive Monthly Fee listed below per Member to include all Covered Healthcare Services included on the Detailed Services List.

$65/ month for adults
$35/ month per child with an adult membership— but capped at two children per family.  
Children without an adult membership— $45/ month— capped at four children per family.
A one-time fee of $100 per person is to be paid upon acceptance of your application and signing of the Membership Agreement.

There are two options for paying your membership fees.  
You can pay for the entire year upfront and get a 10% discount.  
You may also pay monthly with a credit/debit card kept on file through Hint Health.
It is the member’s responsibility to maintain accurate information on file for billing purposes.  

Payment transactions declined due to expired cards will result in an additional fee of $50.  Failure to comply with payment terms may result in termination of membership.  Services will not be rendered to patients with past due accounts.  

No-show fee
While our membership gives you unlimited medical care, individual appointment times are valuable to us, and to our patients. 
Therefore, a $50 no-show fee will be assessed without 48 hours' notice of cancelation or rescheduling of an appointment.

 Most, but not all, of the services described above in Section 2 are covered by the Comprehensive Monthly Fee, subject to the limitations set forth in this Membership Agreement.  However:

Per IRS guidance, if you participate in a high-deductible health plan with a health savings account (HSA) feature, you may be required to pay on a fee-for-service basis for certain primary care, non-preventive care, and urgent care services until such time as your deductible has been satisfied.  If you don’t pay on a fee-for-service basis for these services, it is possible you may lose your ability to contribute to your HSA during your membership.  Please consult your attorney or financial adviser.  FHPC hereby disclaims any responsibility or liability with respect to your decision made thereto.  
Some Health Dare services provided by FHPC are not covered by the Comprehensive Monthly Fee (Non-Covered Health Care Services).  The FHPC fee schedule for these services will be provided to you upon your request.  FHPC may amend the fee schedule from time to time in its sole and absolute discretion and without prior notice.
If you request and receive a Non-Covered Health Care Service you must pay for that service at the time it is provided.  At your request, a claim form that you can submit to your health plan will be provided.
You agree not to submit any claims to any third-party payor or any government health care program for Covered Services rendered by FHPC to you under this Agreement.
All Fees paid are non-refundable.  This includes all fees that may have been paid whether such were paid on a monthly or annual basis.  

4. Your Medical Information
Your privacy is very important to us and you control the use of your personal information.  FHPC has put important safeguards in place to make sure your medical information is protected and safe to maintain its confidentiality.
 You will be able to opt in to obtain your medical information through our secure patient portal.  We will not share any medical information without your written permission in order to safeguard your confidentiality.  If you are referred to a specialist, we will forward appropriate information with such a referral.  
 We will be obligated to share records as required by court or law enforcement written requests.  We will also be obligated to share records on minors as requested (in writing) by a custodial parent.
 This goes a step beyond the statutes set out in the Health Insure Portability and Accountability Act of 1996 (HIPAA).  Other providers may not agree with the confidentiality position that we have taken, but we believe that it is in the best interest of our patients to add this extra layer of security for your protection.
 Records will be provided, by request, without charge for the first copy only.  Additional copies will be provided for a fee as per state regulations.

5. Digital Communications Risks and Conditions
FHPC offers members the ability to send and receive emails and texts to and from their care team.  While FHPC takes precautions to protect your information and the security of the emails and texts it sends, there are still risks.

 Risks:
Transmitting patient information by email or text has a number of risks.  These risks include but are not limited to the following:
Email and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.
Email and text senders can readily misaddress an email or text
Email and texts can be intercepted, altered, forwarded, or used without authorization or detection.
Email and texts may not be secure, and therefore it is possible that the confidentiality of such communications may be breached by a third party.
Email and text service providers may have access to your emails and texts.

 Conditions:
FHPC is not liable for improper disclosure of confidential information that is not caused by FHPC’s misconduct.  You must acknowledge and consent to the following conditions:
 Email and text are not appropriate nor should they be used for urgent or emergency situations.  Please call 911 in the event of a medical emergency.
 Per your request, FHPC may send emails or texts to you as necessary for your diagnosis, treatment, billing, eligibility, and other handling.  You should not use email or text for sensitive communications (e.g. AIDS/HIV, mental health, developmental disability, substance abuse, photographs that could be misconstrued out of context).
 You are responsible for informing FHPC, in writing, if you want to cease or limit email or text communications with FHPC.  You may do so at any time without reason or explanation.  
 You are responsible for protecting your email account or telephone password or other means of access to your email or text.  FHPC is not liable for breaches of confidentiality involving your email or telephone accounts that are caused by you or any third party.

 
By signing this Membership Agreement, you acknowledge that you have received and read the above information.  In addition, you agree to any instructions that FHPC may impose regarding the sending and receipt of an email or text communications containing patient information.  

 
Recommendations and Instructions:
If you wish to send and receive emails or texts from FHPC regarding your care and treatment, you:
—Should limit or avoid the use of public computers and public networks.
—Should promptly inform FHPC of changes in your email address or telephone number
—Before sending emails or texts containing personal health information to FHPC, you should:
* Ensure the email or text is addressed to the intended recipient
* List the key topic in the email subject line
* Put your name in the body of the email or text
Take precautions to preserve the confidentiality of your emails or texts.  Once FHPC sends an email or text from its network, it has no control over its confidentiality or security.

6. Term and Termination
This Membership Agreement shall begin upon the Effective Date and shall continue for one year to the first-anniversary date.  This Agreement will automatically renew on the first-anniversary date and all subsequent anniversary dates thereof unless you provide sixty (60) days written notice prior to the anniversary date.
The Membership Agreement may be terminated within 30 days of the effective date by submission of a Membership Cancellation Form. In that case, you will only be charged the Membership fee and the first month’s Comprehensive Monthly fee.  In the event that the cash value of services rendered during that 30 day period exceeds those fees, you agree to pay the balance of those charges.
After the initial 30 day period, membership is a 12-month minimal commitment.
If you move away from the area we can continue to provide care via phone or telemedicine.  Once you transition care to another provider (i.e. we transfer records) we will cancel your monthly obligation.
Notwithstanding the above, in order to terminate this Membership Agreement, you must complete, sign and submit (via U.S. mail, overnight courier, email, or fax) to FHPC a Membership Cancellation Form.  Membership Cancellation Forms can be obtained by contacting FHPC.  The date of termination shall be the last day of the month that follows the month in which the Membership Cancellation Form was received.  
Upon cancellation, after payment is received for all periods prior to the termination of this Membership Agreement, you will not be responsible for any further payments (except as noted during the initial 30 days described above).
FHPC may terminate this Membership Agreement at any time, subject to any professional obligations. 

7. Future Hope Primary Care Terms
If any term, provision, covenant, or condition of this Membership Agreement is held by a court of competent jurisdiction to be invalid, void, or unenforceable, the remaining provisions will remain in full force and effect and will in no way be affected, impaired or invalidated.  
This Membership Agreement will be governed by and construed in accordance with the laws of the state in which the medical office of your FHPC provider is located.  By signing the Membership Agreement, you agree to have any dispute arising out of the Membership Agreement decided by neutral binding arbitration rather than by a jury or court trial.  Any dispute will be submitted to arbitration in the county in the state where you receive services covered by the Membership Agreement.  The decision in arbitration shall be conclusive and binding on you and FHPC.  All arbitration provisions shall be governed by, construed, and enforce in accordance with the Federal Arbitration Act.
This Membership Agreement is non-transferable.

 

If you have a complaint, please contact FHPC directly or by any of the following ways:

Email: Mark@futurehopetotalhealth.com
Phone:  (502)257-8820
Mail: 
Future Hope Primary Care
231 Midland Park
Shelbyville, KY 40065

 
I acknowledge that I have read and understood all the terms of this agreement.  I have been given the opportunity to address any questions or concerns and they have been answered to my satisfaction.

Future Hope Primary Care
231 Midland Park | Shelbyville, KY 40065
Phone: (502) 257-8820 | Fax: (502) 633-6657

Request For Records

I hereby authorize my PREVIOUS DOCTOR to fax/mail my health information (protected) to Future Hope Primary Care.

• I understand that I can revoke this authorization, in writing, at any time by sending written notification to the above-named practice.
  
• I also understand that my revocation is not effective to the extent that the persons I have authorized to use and/or disclose my protected health information have acted in reliance upon this authorization.
• I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by federal laws and regulations regarding the privacy of my child/children's protected health information.
• I have read and understood the above statement and consent to the release of all Medical Records.