NARCOTICS POLICY: Direct Primary Care Mebane does not manage chronic pain with narcotic prescriptions. If you are in need of chronic pain management, please seek care at a pain management clinic.
MEMBERSHIP. Patient hereby agrees to enroll as a member in Practice’s direct primary care membership program (“Membership Program”) for no less than six months, beginning on the Effective Date set forth above. By being a member of the program, Patient shall be eligible to receive certain basic medical services described on Exhibit A (“Covered Services”), attached here to and made a part here of, and shall be subject to the conditions and limitations described therein. Membership in Practice’s Membership Program includes only the Covered Services specifically described in Exhibit A. Practice may add or discontinue Covered Services at any time, as it may choose in its sole discretion. Practice shall provide at least sixty (60) days’ advance written notice on any change to Covered Services listed in Exhibit A.
MEMBERSHIP FEES. In addition to the one-time registration fee in the amount of fifty dollars ($50.00) per Membership, Patient agrees to pay a monthly fee (“Membership Fee”) in accordance with the schedule attached hereto as Exhibit B, and made a part hereof (“Membership Fee Schedule”). The one-time registration fee is due on the Effective Date hereof. Membership Fees shall be due on the same day as the Registration fee each month following the Effective Date, and will cover the Patient’s membership for the month immediately after. An active credit or debit card must be on file for billing. Any fees or charges not included in the Membership Fee (i.e. fees for procedural services) are due at the time of service. For purposes of this Agreement, “Family” includes only two (2) legal dependents and is limited to two (2) adults.
24 HOUR CANCELLATION AND RESCHEDULING POLICY. If cancellation is necessary, we require that you call or reschedule on line at least 24 hours in advance. Your advanced notice will allow another patient access to that appointment time. Late cancellations and no-shows will be billed a twenty dollars ($20) missed appointment fee.
NONPAYMENT. In the event that the Patient is unable to pay the monthly Membership Fee in full and on time, Practice may, in its sole discretion, terminate this Membership Agreement. It is the Patient's responsibility to maintain a correct and up-to-date credit/debit card number on file.
CHANGES TO MEMBERSHIP FEE SCHEDULE. Practice may amend the Membership Fee Schedule at any time, as it may determine in its sole discretion, upon providing Patient at least 60 days advance written notice.
NON-COVERED SERVICES. Patient understands and acknowledges that Patient is responsible for any charges incurred for health care services performed outside of the physical office space location as set forth above, including, but not limited to, emergency room visits, hospital and specialist care, and imaging and lab tests performed by third parties. Patient shall also be responsible for any charges incurred for health care services provided by Practice but not specifically described on Exhibit A.
The Practice strongly 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.
INSURANCE. Patient acknowledges and understands that this Membership Agreement or Membership in Practice does not provide comprehensive health insurance coverage, nor is it a contract of insurance. Patient represents that patient has contacted Patients health insurance company to discuss any limitations or restrictions that me be imposed upon patient by signing the agreement for self-pay status attached here to and incorporated by reference herein.
INSURANCE CLAIMS. Patient acknowledges and understands that Practice is not a participating provider in any Medicaid, Medicare or private health care plan. Patient acknowledges and understands that Practice will not bill insurance carriers on Patient’s behalf for Covered Services provided to Patient, and Practice will not bill any health care plan of which the Patient may be a subscriber or beneficiary for Membership Fees due and owing to Practice under this Membership Agreement. Membership Fees may not be submitted to insurance companies for reimbursement.
TAX-ADVANTAGED MEDICAL SAVINGS ACCOUNTS. It is the responsibility of the patient to communicate with their HSA (Health Savings Account), MSA (Medical Savings Account), or FSA (Flexible Savings Account) benefit advisor to determine if the membership fees constitute eligible medical expenses that are payable or reimbursable under their plan. Any charges accrued from services rendered by the Practice that are denied by the Patient’s third-party payer remain the Patient’s responsibility and must be paid in full by the Patient.
HEALTH PLANS. Because Practice is not a participating provider in Medicaid, Medicare or private health care plan, third party payers may not count the Membership Fees incurred pursuant to this Membership Agreement toward any deductible Patient may have under a health plan. Patient should consult with their health benefits advisor regarding whether Membership Fees may be counted toward the Patient’s deductible under a health plan, as may be applicable. Patient acknowledges through this Membership Agreement that neither Practice, nor its Providers, participate in any health insurance, Medicaid, HMO plans or panels, and have opted out of Medicare.
Patient acknowledges through this Membership Agreement that Patient understands this Membership Agreement is not an insurance plan or a substitute for health insurance. Patient understands that this Membership Agreement does not replace any existing or future health insurance or health plan coverage that the Patient may carry. The Agreement does not include hospital services, or any services not personally provided by Practice or its staff. The Patient acknowledges by signing this agreement that the Patient has been advised to obtain or keep in full force, health insurance that will cover hospitalizations, catastrophic events, and all other healthcare services not personally provided by Practice.
MEDICARE. Patient acknowledges by signing this Membership Agreement that the Patient understands and agrees that the Provider has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for the Patient by the Provider. The Patient agrees not to submit a bill to Medicare or attempt to obtain Medicare reimbursement for any such services. If the Patient is eligible for Medicare, or becomes eligible during the term of the Agreement, then the Patient will sign the Opt Out and Waiver Agreement. The Patient shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law.
TERMINATION OF AGREEMENT. Termination of this Membership Agreement shall cause the termination of Patient’s membership in the Membership Program described herein. No more than a 30-day medication refill can be provided with the mandatory 30-day’s notice of termination.
TERMINATION BY PRACTICE. Practice may terminate this Membership Agreement upon providing Patient advance written notice. Termination will be effective starting five business days after notification. Upon termination, Practice shall comply with all rules and regulations of the State of North Carolina regarding the provision of emergent care for 30 days after termination. Costs for an Urgent Care appointment will apply. Practice will cooperate in the transfer of the Patient’s medical records to the Patient’s new primary care provider, upon the Patient’s written request and direction.
LATE PAYMENT OF MEMBERSHIP. Patient cards on file that reject their monthly membership draft have 30 days to place a new card on file and notify the practice or be subject to a $25 late fee. If a second monthly membership draft is rejected, Patient is automatically unenrolled form the practice Patient understands that upon early cancellation any remaining balance owed will be immediately due and will be charged to patients card on file. If the fair market value of the services received over the term of the Membership Agreement exceed the amount Patient paid in fees, Patient shall reimburse Practice in an amount equal to the difference between the fair market value of the services received and the amount Patient paid in membership fees over the term of the Membership Agreement. The Parties agree that the fair market value of the services is equal to Practice’s usual and customary fee-for-service charges. A copy of these fees are available on request.
TERMINATION BY PATIENT. Patient may terminate this Membership Agreement at any time and for any reason, upon providing 30 days advance written notice to Practice. Such termination shall be effective on the last day of the then-current membership month. Membership Fees shall not be pro-rated for any terminal month. Monthly Membership Fees will continue to accrue until Patient’s written notice of termination is received by Practice at its office location set forth above. If the fair market value of the services received over the term of the Membership Agreement exceed the amount Patient paid in fees, Patient shall reimburse Practice in an amount equal to the difference between the fair market value of the services received and the amount Patient paid in membership fees over the term of the Membership Agreement. The Parties agree that the fair market value of the services is equal to Practice’s usual and customary fee-for-service charges. A copy of these fees are available on request.
Patient understands that upon early cancellation any remaining balance owed will be immediately due and will be charged to patients card on file.
REINSTATEMENT. In the event Patient terminates this Membership Agreement after the Effective Date hereof, Patient shall be ineligible for membership for a period of six (6) months following the effective date of termination, unless Patient pays a reinstatement fee in the amount of fifty dollars ($50.00) (Reinstatement Fee).
INDEMNIFICATION. Patient agrees to indemnify and to hold Practice 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 Practice as a result of the Patient’s breach of any of Patient’s obligations under this Agreement.
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 Practice 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 Practice or Patient.
GOVERNING LAW. This Agreement and the rights and obligations of Practice and Patient hereunder shall be construed and enforced pursuant to the laws of the State of North Carolina.
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 Practice under this Membership Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and Practice reasonably believes in good faith that the change will have a substantial adverse effect on Practice’s rights, obligations or operations associated with this Membership Agreement, then Practice 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 with ten (10) days after the effective date of change, then Practice may immediately terminate this Membership Agreement upon providing written notice to the Patient.
ASSIGNMENT/BINDING EFFECT. This Membership Agreement shall be binding upon and shall inure to the benefit of both Practice 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 Practice.
I understand if I have an unpaid balance to Direct Primary Care Mebane and do not make satisfactory payment arrangements, my account may be placed with an external collection agency. I will be responsible for reimbursement of the fee of any collection agency, which may be based on a percentage at a maximum of 35% of the debt, and all costs and expenses, including reasonable collection and attorney’s fees incurred during collection efforts.
In order for Direct Primary Care Mebane or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that Direct Primary Care Mebane and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable. Furthermore, I consent the designated external collection agency to share personal contact and account related information with third party vendors to communicate account related information via telephone, text, e-mail, and mail notification.
IN WITNESS WHEREOF, the parties have caused this Membership Agreement to be effective on the Effective Date first written above.