PRACTICE PARTICIPANT AGREEMENT

Transcription

1 PRACTICE PARTICIPANT AGREEMENT this is an Agreement entered into on, 20, by and between Olathe LAD Clinic, LLC (Diana Smith RN, LPC, ARNP) a Kansas professional company, located at 1948 E Santa Fe, Suite H, Olathe, KS 66062, in her capacity as an agent of Olathe LAD Clinic, LLC and, (Practice Participant). Background Diana Smith RN, LPC, ARNP, who specializes in Lyme and Associated Diseases, delivers care on behalf, at the address set forth above. In exchange for certain fees paid by Practice Participant, Olathe LAD Clinic, LLC, through its Nurse Practitioner, agrees to provide Practice Participant with the Services described in their Agreement on the terms and conditions set forth in their Agreement. Definitions: A. Practice Participant. A Practice Participant is defined as those persons for whom the Nurse Practitioner shall provide Services, and who are signatories to, or listed on the documents attached as Appendix 1, and incorporated by reference, to their agreement B. Services. As used in their Agreement, the term Services, shall mean a package of services both medical and non-medical and certain amenities (collectively Services ), which are offered by, and set forth in Appendix Terms. their agreement shall commence on the date signed by the parties below and shall continue for a period of one year, automatically renewed. 2. Fees. In exchange for the services described herein, Practice Participant agrees to pay, the amount as set forth in Appendix 1, attached. their fee is payable upon execution of their agreement, and is in payment for the services provided to Practice Participant during the term of their Agreement. If the Agreement is cancelled by either party before the agreement termination date, then Olathe LAD Clinic, LLC shall refund the Practice Participant s prorated share of the original payment, remaining after deducting individual charges for services rendered to Practice Participant up to cancellation. 3. Non-Participation in Insurance. Practice Participant acknowledges that neither, nor the Nurse Practitioner participate in any health insurance or HMO plans or panels and has opted out of Medicare. Neither of the above make any representations whatsoever that any fees paid under the Agreement are covered by your health insurance or other third party payment plans applicable to the Practice Participant. The Practice Participant shall retain full and complete responsibility for any such determination. If the Practice Participant is eligible for Medicare, or during the term of their Agreement becomes eligible for Medicare, then Practice Participant will sign the agreement attached as Appendix 2, and incorporated by reference. the agreement acknowledges your understanding that the Nurse Practitioner has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for you by the Nurse Practitioner. You agree not to bill Medicare or attempt Medicare reimbursement for any such services. Practice Participant shall renew and sign the agreement in Appendix 2 yearly.. 4. Insurance or Other Medical Coverage. Practice Participant acknowledges and understands that the Agreement is not an insurance plan, and not a substitute for health insurance or other health plan coverage (such as Practice Participant in an HMO). It will not cover hospital services, or any services not personally provided by Olathe LAD Clinic, LLC, or its Nurse Practitioners. Practice Participant acknowledges that Diana Smith RN, LPC, ARNP has advised that Practice Participant obtain or keep in full force such health insurance policy(ies) or plans that will cover Practice Participant for general healthcare costs. Practice Participant acknowledges that their Agreement is not a contract that provides health insurance and their Agreement is not intended to replace any existing or future health insurance or health plan coverage that Practice Participant may carry.

2 5. Term/Termination. their Agreement will commence on the date first written above and will extend yearly thereafter. Notwithstanding the above, both Practice Participant and Diana Smith RN, LPC, ARNP shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination, upon giving 30 days prior written notice to the other party. Olathe LAD Clinic, LLC will refund only those pre-paid fees that were paid for the calendar days between the end of the 30 day notification as outlined above and the end of the current agreement period. Such refund shall be reduced by any fees due for office visits or medical services provided outside of the pricing schedule below. 6. Communications. You acknowledge that communications with the Nurse Practitioner using , facsimile, video chat, instant messaging, and cell phone are not guaranteed to be secure or confidential methods of communications. As such, Practice Participant expressly waives the Nurse Practitioner s obligation to guarantee confidentiality with respect to correspondence using such means of communication. You acknowledge that all such communications may become a part of your medical records. By providing Practice Participant s address on the attached Appendix 1, Practice Participant authorizes, and its Nurse Practitioners to communicate with Practice Participant by regarding Practice Participant s protected health information (PHI) (as that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and it s implementing regulations) By inserting Practice Participant s address in Exhibit 1, Practice Participant acknowledges that: (a) is not necessarily a secure medium for sending or receiving PHI and, there is always a possibility that a third party may gain access; (b) Although and the Nurse Practitioner will make all reasonable efforts to keep communications confidential and secure, neither, nor the Nurse Practitioner can assure or guarantee the absolute confidentiality of communications; (c) At the discretion of the Nurse Practitioner, communications may be made a part of Practice Participant s permanent medical record; and, (d) Practice Participant understands and agrees that is not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation in which the member could reasonably expect to develop into an emergency, Member shall call 911 or the nearest Emergency room, and follow the directions of emergency personnel. If Practice Participant does not receive a response to an message within one day, Practice Participant agrees to use another means of communication to contact the Nurse Practitioner. Neither, nor the Nurse Practitioner will be liable to Practice Participant for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Practice Participant as a result of technical failures, including, but not limited to, (i) technical failures attributable to any internet service provider, (ii) power outages, failure of any electronic messaging software, or failure to properly address messages, (iii) failure of the Practice s computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of communications by a third party; or (v) your failure to comply with the guidelines regarding use of communications set forth in their paragraph. 7. Change of Law. If there is a change of any law, regulation or rule, federal, state or local, which affects the Agreement including these Terms & Conditions, which are incorporated by reference in the Agreement, or the activities of either party under the Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and either party reasonably believes in good faith that the change will have a substantial adverse effect on that party s rights, obligations or operations associated with the Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms of the Agreement including these Terms & Conditions. If the parties are unable to reach an agreement concerning the modification of the Agreement within forty-five days after of date of the effective date of change, then either party may immediately terminate the Agreement by written notice to the other party.

3 8. Severability. If for any reason any provision of their Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of the Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable. 9. Reimbursement for services rendered. If their Agreement is held to be invalid for any reason, and if is therefore required to refund all or any portion of the monthly fees paid by Practice Participant, Practice Participant agrees to pay an amount equal to the reasonable value of the Services actually rendered to Practice Participant during the period of time for which the refunded pre-paid fees were paid. 10. Amendment. No amendment of their Agreement shall be binding on a party unless it is made in writing and signed by all the parties. Notwithstanding the foregoing, the Nurse Practitioner may unilaterally amend their Agreement to the extent required by federal, state, or local law or regulation ( Applicable Law ) by sending Practice Participant 30 days advance written notice of any such change. Any such changes are incorporated by reference into their Agreement without the need for signature by the parties and are effective as of the date established by, except that Practice Participant shall initial any such change at s request. Moreover, if Applicable Law requires their Agreement to contain provisions that are not expressly set forth in their Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into their Agreement and shall be deemed a part of their Agreement as though they had been expressly set forth in their Agreement. 11. Assignment. their Agreement, and any rights Practice Participant may have under it, may not be assigned or transferred by Practice Participant. 12. Relationship of Parties. Practice Participant and the Nurse Practitioner intend and agree that the Nurse Practitioner, in performing her duties under their Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and/or the United States Department of Labor, and the Nurse Practitioner shall have exclusive control of her work and the manner in which it is performed. 13. Legal Significance. Practice Participant acknowledges that their Agreement is a legal document and creates certain rights and responsibilities. Practice Participant also acknowledges having had a reasonable time to seek legal advice regarding the Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of the Agreement. 14. Miscellaneous; their Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted. Captions in their Agreement are used for convenience only and shall not limit, broaden, or qualify the text. 15. Entire Agreement: their Agreement contains the entire agreement between the parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of their Agreement. 16. Jurisdiction: their Agreement shall be governed and construed under the laws of the State of Kansas and All disputes arising out of their Agreement shall be settled in the court of proper venue and jurisdiction for 1948 E Santa Fe, Suite H in Olathe, Kansas. 17. SERVICE. All written notices are deemed served if sent to the address of the party written above or appearing in Exhibit A by first class U.S. mail.

4 The parties have signed duplicate counterparts of their Agreement on the date first written above. By Diana Smith RN, LPC, ARNP, President of Olathe LAD Clinic, LLC Practice Participant: Printed Name Signature

5 Appendix 1 Practice Participant Annual Fees: The Practice Participant annual fee (this does not pertain to the All ll-i -Inclusive Practice Participant): Each additional office visit will be charged at a rate of $2/minute with a minimum visit time of 10 minutes. Beginning 5/1/1 1/13 through 5/31/13, Practice Participant Basic Membership fees are as follows: $ /yr, $ /qtr, or $13 130/month; three month s fees required for new Practice Participant then monthly payments accepted (initial 3 month fee is non-refundable) Beginning 5/1/13 through 5/31/13 Practice Participant All-I -Inclusive Membership fees are as follows: $2400/yr 00/yr, $660/qtr, or $225/month; three month s fees required for new Practice Participant then monthly payments accepted (initial 3 month fee is non-refundable) Covers unlimited regular hours visits to the clinic. It also provides for direct access to Diane Smith RN, LPC, ARNP by cell phone or 24/7. After hours visits would be covered as well when needed and feasible. Virtual visits are also included. Appointments will be time based, with the amount of time for the appointment chosen by the Practice Participant at the time of scheduling. The time of these appointments will be strictly enforced so that we can avoid excessive waiting times for other Practice Participants that follow.

6 Beginning 5/1/1 1/13 through 5/31/13, Maintenance Plan annual fees are as follows: $400 per year for up to 2 visits Practice Participant address:

7 Appendix 2: Diana Smith RN, LPC, ARNP 1948 E Santa Fe, Suite H Olathe, KS Phone Fax Private Contract : The agreement is between Diana Smith RN, LPC, ARNP, whose principal place of business is: 1948 E Santa Fe, Suite H Olathe, KS and Beneficiary: Who resides at: Medicare ID #: and is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of The Nurse Practitioner has informed Beneficiary or his/her legal representative that Nurse Practitioner has opted out of the Medicare program effective on May1, 2013 for a period of at least two years, to expire on April 30, The Nurse Practitioner is not excluded from participating in Medicare Part B under [1128] 1128, [1156] 1156, or [1892] 1892 of the Social Security Act. Beneficiary or his/her legal representative agrees, understands and expressly acknowledges the following:

8 Beneficiary or his/her legal representative accepts full responsibility for payment of the Nurse Practitioner s charge for all services furnished by the Nurse Practitioner. Beneficiary or his/her legal representative understands that Medicare limits do not apply to what the Nurse Practitioner may charge for items or services furnished by the Nurse Practitioner. Beneficiary or his/her legal representative agrees not to submit a claim to Medicare or to ask the Nurse Practitioner to submit a claim to Medicare. Beneficiary or his/her legal representative understands that Medicare payment will not be made for any items or services furnished by the Nurse Practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. Beneficiary or his/her legal representative enters into the contract with the knowledge that he/she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and the beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out. Beneficiary or his/her legal representative understands that Medi- Gap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. Beneficiary or his/her legal representative acknowledges that the beneficiary is not currently in an emergency or urgent health care situation. Beneficiary or his/her legal representative acknowledges that a copy of their contract has been made available to him/her. Executed on:, 20 By: Beneficiary or his/her legal representative And: Diana Smith RN, LPC, ARNP