Terms of service.
In exchange for certain fees paid by Patient, the Physician agrees to provide patient with the services described in this Agreement on the terms and conditions set forth in said Agreement. Due to the unique nature of the membership-based practice model, the Physician and Patient have entered into this Agreement in order to clarify the nature and understanding of the services provided.
The patient agrees to pay Physician the agreed upon fees that are listed on the enrollment form at the agreed interval. These fees are listed in Attachment A – “Office Policies.” The Physician may modify these fees at the beginning of any calendar year with 60 days’ notice. These fees will be for medical services as listed below.
The medical services that will be provided at no additional charge are those that would be delivered in a general pediatrics practice environment. The Patient has also reviewed and signed the “Consent for Treatment.”
Services provided as part of the general pediatrics membership will include, but are not necessarily limited to the following:
All home visits, including: an annual health maintenance exam, sports, daycare and school physicals; sick/acute care visits, and chronic condition management for patients aged newborn-21 years.
Telephone, text, email, and video consults as determined appropriate by Physician with Patient agreement.
Routine immunization administration according to the CDC recommended schedule of vaccinations. (The cost of the immunizations themselves will be provided and billed separately by a third-party vendor, or may be cash pay by patient at the time of service if requested by patient.)
Coordination with specialty care providers to ensure proper communication between providers on your medical team.
Completion by Physician of required school or other institution forms if patient is up-to-date on appropriate wellness and/or medical condition follow-up, with up to 7 days turnaround time.
Non-medical services covered under this Agreement
Physician will make every effort to be available at all times via phone, e-mail, & other methods such as “after hours” appointments when appropriate, but Physician cannot guarantee 24/7 availability. If you are having a medical emergency, please call 911.
During the Physician’s absence, an appropriate licensed healthcare provider contact will be provided.
E-mail access will be provided for non-urgent communication.
Physician visits will be by appointment only.
Acute care appointments will be guaranteed on the same or following day Monday-Friday with the understanding that this visit may be virtual as deemed appropriate by Physician.
Hospital visits of a social nature if patient is hospitalized, when Physician is able; Coordination of care as appropriate with communication with hospitalist upon admission and discharge and additionally as necessary or if requested by Patient.
The Patient understands that they may occasionally incur additional small fees to cover supplies for procedures, vaccines if family is choosing not to use insurance, medications (such as albuterol). Any charges above the monthly membership fee will be disclosed by the Physician to the Patient prior to providing the service.
The Patient consents to medical services provided by Physician or other trained medical staff at the Practice.
The Patient acknowledges that any visits conducted virtually (phone, video, text, or e-mail) have limitations due to the inability to conduct a thorough physical examination of the Patient, and can be limited by technological mishaps. Patient agrees to these virtual visits when deemed appropriate by the physician and will alert the Physician at the time of service if the Patient is uncomfortable with this method of evaluation for any reason. The patient can request an in-person visit as an alternative and the Physician will do all in her power to provide this in-person visit in a timely manner, but this cannot be guaranteed. The patient agrees not to hold the physician liable for any information not received due to mishaps with technology.
This agreement is not a substitute for health insurance. Patient acknowledges that the Physician nor the Practice participates in any insurance or HMO plans.
Physician is not contracted with any private insurers or Medicare. Physician is an Ordering, Referring, and Prescribing provider with Illinois Medicaid, but is not contracted to be a treating physician with Medicaid. Patient acknowledges that federal regulations REQUIRE that Physicians opt out of Medicare so that Medicare patients may be seen by the practice pursuant to this private direct primary care contract.
It is in the Patient’s best interest to obtain and/or continue current healthcare coverage for themselves. Patient must understand that all services performed by outside providers are payable directly to those providers, and that the Physician will not be involved in submitting insurance claims.
Patient also agrees and understands that he or she is responsible for the payment of the enrollment fee and the age-based membership fee set forth on the enrollment forms (and can be viewed as Attachment A). If Patient does not meet their financial obligation, the Physician has the right to terminate this Agreement. The fee is earned and not refundable on the first day of each month. The fee for the initial month will be prorated if the contract is signed on any date other than the 1st of the month.
Enrollment fee: $150 per family at time of enrollment of first family member (non-refundable)Ages 0-6 months: $200/month
Ages 6 months - 5 years: $150/month
Over 5 years: $125/month
There may be occasional nominal fees for lab work (point of care testing), imaging or other diagnostic tests, or treatment supplies that will be disclosed at the time of service and due at that time.
ITP reserves the right to make adjustments to the above membership fees at any time, with 60 day notice to members.
This Agreement will be effective on the date written above and it will extend through the end of the calendar year.
This Agreement may be terminated without showing cause with a 30-day prior written notice by Physician and/or Patient. There are no penalties for patient cancellation, with the except of newborns or babies under 6 months old who will be responsible for monthly payments until the baby is 6 months old and will need to pay the remainder of any unpaid months at the time of termination. The Agreement shall be terminated upon the death of either Physician or Patient. The Agreement will automatically be renewed at the end of each calendar year with the payment of current fees at the end of the contract year. If this agreement is terminated by the family and the family decides to re-enroll at a later date, they will incur a $350 re-enrollment fee. The following are examples or reasons that the Practice may wish to terminate the Agreement with the Patient:
The Patient fails to pay applicable fees owed pursuant to Physician age bracketed fee schedule;
The Patient has performed an act that constitutes fraud;
The Patient repeatedly fails to adhere to the recommended treatment plan;
The Patient is abusive, or presents an emotional or physical danger to the Physician or any future employed or contracted staff;
The Physician deems the Patient’s home environment or surroundings unsafe for Physician.
Practice discontinues operation; and
Practice has a right to determine whom to accept as a patient, just as a patient has the right to choose his or her physician;
The Practice may also terminate a patient without cause as long as the termination is handled appropriately (without violating patient abandonment laws).
The Patient Acknowledges that this agreement is a legal document and creates certain rights and responsibilities. You also acknowledge that you have a right to seek legal counsel regarding this Agreement and either have chosen not to do so or have done so and are satisfied with the terms and conditions of the agreement.
Patient also acknowledges that In Touch Pediatrics and Lactation, PLLC and/or Physician has the right to amend this agreement by notifying Patient in writing of the proposed amendments, which will become effective no earlier than 60 days following such proposed amendment. Patient will be deemed to have agreed to the amendment unless Patient notifies Physician in writing that he or she does not agree to such amendment, in which event this agreement will be terminate in the same time and manner as described in Paragraph 9 above.
Patient acknowledges that communications with the Physician using e-mail, facsimile, video chat, instant messaging and cell phone are not guaranteed to be secure or confidential methods of communications. The practice will make an effort to secure all communications via passwords and other protective means and these will be discussed in an annually updated Health Insurance Portability and Accountability Act (HIPAA) Confidentiality Agreement I have reviewed the current HIPAA and agree to its terms.
Patient Understandings:
This agreement is for ongoing primary care and is NOT a medical insurance agreement.
I have read the “Office Policies” and agree to the terms therein.
I do NOT have an emergent medical problem at this time.
In the event of a medical emergency, I agree to call 911 first.
I do NOT expect the practice to file or fight any third-party insurance claims on my behalf.
In the event I have a complaint about the practice I will first notify the Practice directly.
This Agreement (without a “wrap around” compliant insurance policy) does not meet the individual insurance requirement of the ACA.
I am enrolling the Patient in the practice voluntarily.
I may receive a copy of this document upon request.
This Agreement is non-transferable.
Additional Terms.
No Assignment. This Agreement may not be assigned by either party without the written consent of the other party.
Successors and Assigns. This Agreement is binding upon, and inures to the benefit of, the parties and their respective or permitted successors and assigns.
Term. This Agreement may be terminated by mutual agreement of the parties, and shall automatically terminate upon completion of all responsibilities as stated herein, unless otherwise amended. This Agreement shall otherwise remain in full force and effect and shall govern all Events mutually undertaken by the Parties.
Further Actions. The Parties hereby agree to execute any further documents and to take any necessary actions to complete this transaction.
Governing Law; Venue. This Agreement will be governed and interpreted in accordance with the laws of the State of Illinois without regard to its laws of conflicts. Any legal action brought concerning this Agreement or its subject matter will be brought only in the state and federal courts located in Illinois, and both parties agree to the exclusive jurisdiction and venue of these courts.
Cumulative Remedies. All rights and remedies provided in this Agreement are cumulative and not exclusive of any other rights or remedies that may be available to the parties, whether provided by law, equity, statute, in any other agreement between the parties, or otherwise.
Force Majeure. A party is not liable for failure to perform the party's obligations if such failure is a result of Acts of God (including fire, flood, earthquake, storm, hurricane or other natural disaster), war, invasion, act of foreign enemies, hostilities (regardless of whether war is declared), civil war, rebellion, revolution, insurrection, military or usurped power or confiscation, terrorist activities, government sanction, blockage, embargo, labor dispute, strike, lockout or interruption or failure of electricity or telephone service.
No Waiver. No waiver by any party of any of the provisions hereof will be effective unless expressly set forth in writing and signed by the waiving party. No waiver by a party will operate or be construed as a waiver in respect of any failure, breach or default not expressly identified by such written waiver, whether of a similar or different character, and whether occurring before or after that waiver. No failure to exercise, or delay in exercising, any right, remedy, power or privilege arising from this agreement will operate or be construed as a waiver thereof; nor shall any single or partial exercise of any right, remedy, power or privilege hereunder preclude any other or further exercise thereof or the exercise of any other right, remedy, power or privilege.
Severability. If any provision of this agreement is held to be unenforceable, the enforceability of the remaining provisions of this agreement are not affected and will remain in full force as though the unenforceable provision were omitted from the agreement.
Entire Agreement. This Agreement constitutes the final and exclusive agreement between the parties relating to this subject matter and supersedes all other prior and contemporaneous negotiations, discussions, and agreements of any kind, whether written or oral, concerning such subject matter.