Consent. I consent to, acknowledge, and understand that my COVID-19 test ("Test") will require the collection of an appropriate sample by my healthcare provider through a nasopharyngeal swab, oral swab, or other recommended collection procedures. The test has been authorized by the FDA under an Emergency Use Authorization. I understand that there are risks and benefits associated with undergoing a test for COVID-19 and there may be a potential for false positive or false negative test results. I understand that there is a possibility of error and that a negative result does not exclude the possibility of COVID-19 and additional tests may be required since SARS-CoV-2 RNA was not present in my specimen above the limit of detection. I relinquish 4 Elements Direct Primary Care from any and all injury, physical or psychological, which might arise from collecting and testing these specimens and from any effects or actions that the results of these tests may have on me or any other concerned individual. This agreement for testing is subject to and shall be enforced in accordance with the laws of the State of Connecticut. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have question or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider. I furthermore understand that this test is a one-time occurrence and by obtaining this test, this visit in and of itself it does not establish an ongoing doctor-patient relationship, and I will seek subsequent medical care with my primary care provider, an urgent care center, or the emergency department at a local hospital.
Payment Policy. 4 Elements Direct Primary Care LLC (4E DPC) does not accept insurance for the test., and does not participate in Medicare or Medicaid programs. Testing services purchased through this website are solely my financial responsibility. Payment is required at time of booking. 4E DPC does not submit any claims directly to insurance, but they can provide itemized receipts 1-day after my test, with all appropriate codes and information needed for an easy submission experience. For medical claims, I must contact my insurance carrier for a claim form. 4 Elements Direct Primary Care will provide me with a receipt with information that will be helpful to me in submitting my claim. Reimbursements are at the discretion of my insurance carrier. Per the Medicare Opt-Out Agreement below, Medicare and Medicaid beneficiarie are not eligible to submit claims for reimbursement.
4 Elements Direct Primary Care LLC does not guarantee insurance reimbursement, and only provides one standardized form of receipt. I will be sure to check my out-of-network benefits summary or call my insurance company directly to verify my coverage and benefits for out of network COVID-19 testing. If I am filing an insurance claim, I will ensure that my insurance company is instructed to pay me directly. Should 4E DPC receive a check on my behalf, it will be returned and the check will have to be reissued to me by my insurance company.
Cancellation Policy. Please understand that appointment times are limited. If you must cancel your appointment, we require 48 hours notice, and your appointment will be refunded with the exception of $10 to cover credit card transaction fees. Missed appointments, or appointments cancelled without 48 hours notice will incur a fee in the full amount of the requested service.
Test Result and Consent to Disclose. I understand that 4 Elements Direct Primary Care LLC may release my test results to my primary care medical provider as noted below in this form without needing any additional release document. I understand that 4E DPC reserves the right to provide identified or in some cases de-identified information of statistical nature to Government agencies and reserves the right to use such anonymous information for validation and research purposes. By signing below, I consent to the disclosure of COVID Test to public health authorities as requested, recommended or required by federal, state, and local public health authorities.
Telehealth Informed Consent to Treat. From time to time, 4E DPC may elect to provide care to the Patient via Telehealth. For the purpose of this Consent, Telehealth is defined as the electronic communications technologies used by the staff members of 4E DPC, to enable them to obtain information and communicate remotely in order to provide patient care. I understand that the same standard of care applies to medical treatment obtained through telehealth communications as applies to an in-person visit. The information obtained through telehealth communications may be used for diagnosis, treatment, follow-up and/or education, and may include any of the following: a) Patient medical records, b) Medical images, c) Live two-way audio and video and data communications, d) Output data from medical devices and sound and video files, e) Questionnaires, f) email and g) text messaging. The electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Possible benefits of Telehealth include a) Easier access to medical care; b) Convenience; c) More time efficient medical evaluation and management. As with any technology used in medical care, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to: a) Information transmitted may not be sufficient to allow for appropriate medical decision making by the physician; b) Physician may not be able to provide medical treatment for your particular conditions remotely; c) Regulatory and other requirements may limit your physician’s ability to provide certain treatment options, including prescriptions; d) Delays in medical evaluation and treatment could occur due to deficiencies or failures in technology equipment; e) Security protocols could fail, resulting in privacy breaches of personal medical information. Patient acknowledges the risks and benefits and consent to the use of Telehealth.
Disclaimer to Treat. 4 Elements Direct Primary Care LLC has been engaged for the sole limited purpose of providing a Test and disclaims any obligation to treat me or provide me with any medical care. I have the right to discuss the Test with my own physician, to learn about the purpose, potential risks and benefits of any testing. Based upon my test results, I will contact my physician or other medical professional for advice and medical care.
Waiver of Liability and Indemnification. By signing below, I, on behalf of myself, my heirs, executors, administrators, assigns, or personal representatives agree to forever release and waive any claim arising from my selection to receive this Test or the disclosure of my test results that may arise against 4 Elements Direct Primary Care LLC and their affiliates, managers, members, agents, staff, heirs, representatives, predecessors, successors and assigns. Additionally, I agree to forever release and waive any claim that might arise against Everpoint and staff members for any risks, side effects, or complications resulting from the Test or the disclosure of my test results. I agree to indemnify and hold harmless 4 Elements Direct Primary Care LLC and their affiliates, managers, members, agents, staff, heirs, representatives, predecessors, successors and assigns against any and all claims, suits, or actions of any kind whatsoever for liability, damages, compensation, or otherwise brought by me or anyone on my behalf, including attorney’s fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf.
Medicare Opt-Out Agreement. The Balanced Budget Act of 1997 allows physicians to “opt out” of Medicare and enter into private contracts with patients who are Medicare beneficiaries. In order to opt out, physicians are required to file an affidavit with each Medicare carrier that has jurisdiction over claims that they have filed (or that would have jurisdiction over claims had the physicians not opted out of Medicare). In essence, the physician must agree not to submit any Medicare claims nor receive any payment from Medicare for items or services provided to any Medicare beneficiary for two years. This Agreement between 4 Elements Direct Primary Care ("4EDPC") and me is intended to be the agreement physicians are required to have with Medicare beneficiaries when physicians opt-out of Medicare. This Agreement is limited to the financial agreement between 4E DPC and Patient and is not intended to obligate either party to a specific course or duration of treatment. I understand that 4E DPC and its Physicians have not been excluded from participation under the Medicare program under section 1128, 1156, 1892, or any other sections of the Social Security Act.
As part of this agreement, 4E DPC agrees to the following:
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4E DPC agrees to provide Patient such treatment as may be mutually agreed upon and at mutually agreed upon fees.
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4E DPC agrees not to submit any claims under the Medicare program for any items or services, even if such items or services are otherwise covered by Medicare
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4E DPC agrees not to execute this contract at a time when Patient is facing an emergency or urgent healthcare situation.
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4E DPC agrees to provide Patient with a signed copy of this document before items or services are furnished to Medicare beneficiary under its terms.
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4E DPC also agrees to retain a copy of this document for the duration of the opt-out period.
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4E DPC agrees to submit copies of this contract to the Centers for Medicare and Medicaid Services (CMS) upon the request of CMS.
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Patient agrees to pay for all items or services furnished by 4E DPC and understands that no reimbursement will be provided under the Medicare program for such items or services.
As part of this agreement, I agree to the following:
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I understand that no limits under the Medicare program apply to amounts that may be charged by 4E DPC for such items or services.
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I agree not to submit a claim to Medicare and not to ask 4E DPC to submit a claim to Medicare.
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I understand that Medicare payment will not be made for any items or services furnished by 4E DPC that otherwise would have been covered by Medicare if there were no private contract and a proper Medicare claim had been submitted.
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I understand that I have the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that I am not compelled to enter into private contracts that apply to other Medicare-covered items and services furnished by other physicians or practitioners who have not opted out of Medicare.
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I understand that Medigap plans (under section 1882 of the Social Security Act) do not, and other supplemental insurance plans may elect not to, make payments for such items and services not paid for by Medicare.
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I understand that CMS has the right to obtain copies of this contract upon request.