Fishers Direct Family Care Member Agreement
Patient acknowledges that execution of this Services Agreement is an application to join FISHERS DIRECT FAMILY CARE LLC, medical practice as a patient. FISHERS DIRECT FAMILY CARE LLC, in its sole discretion, may accept or reject any Patient at any time for any reason. If Patient is accepted by FISHERS DIRECT FAMILY CARE LLC, this Agreement shall govern the ensuing business relationship.
SERVICES AGREEMENT BETWEEN PATIENT AND PRACTICE
READ THIS CAREFULLY. THIS IS AN AGREEMENT BETWEEN FISHERS DIRECT FAMILY CARE LLC, AN INDIANA LIMITED LIABILITY COMPANY (“PRACTICE”), AND YOU, (“PATIENT”).
In exchange for certain fees paid by you as the Patient, Practice, through its physicians and staff, agrees to provide you with the Services described in this Agreement according to the terms and conditions herein.
1. Patient. A patient is defined as those persons for whom the Practice shall provide Services, and who are signatories to, or listed on the documents incorporated by reference to, this Agreement.
2. Services. As used in the Agreement, “Services” shall mean those medical and non-medical services that the Practice’s physicians and staff are permitted to perform, that are consistent with their training and experience, and that are set forth in the Practice’s “Schedule of Services,” which is subject to change.
3. Fees. In exchange for the Services provided to Patient during the term of this Agreement, Patient agrees to pay Practice the amount set forth in the Schedule of Services (according to Patient’s chosen level of Services) as well as any corresponding price lists. Payment of Fees is due at the time Services are rendered unless otherwise specified. If this Agreement is cancelled by either party before the Agreement termination date, Practice shall refund, according to schedule set forth by Practice, the Patient’s prorated share of the original payment remaining after deducting all charges for services rendered to Patient and other administrative fees up to and including date of termination.
4. Non-participation in Insurance. Patient acknowledges the following:a. The Practice (and/or its physicians) may not participate in private or public insurance programs.B. NO REPRESENTATIONS WHATSOEVER ARE MADE THAT ANY FEES PAID UNDER THIS AGREEMENT ARE COVERED AND/OR ELIGIBLE FOR REIMBURSEMENT BY YOUR HEALTH INSURANCE OR OTHER THIRD PARTY PAYMENT PLANS APPLICABLE TO THE PATIENT. The Patient shall retain full and complete responsibility for any such determination.
c. If the Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, Patient at the request of Practice, shall additionally acknowledge and execute a private contract between Medicare-eligible patient and practice.
5. Insurance or Other Medical Coverage. Patient acknowledges that this Agreement is not an insurance plan nor a contract that provides health insurance. This Agreement is not a substitute for health insurance or other health plan coverage. It does not cover hospital services, nor any services not personally provided by Practice. Patient is advised to obtain and keep in full force such health insurance policy(s) or plans that will cover Patient for general healthcare costs.
6. Term; Termination. This Agreement will commence on the Effective Date and continue for a term of two (2) months provided Patient fully complies with the terms and conditions of this Agreement upon commencement, including without limitation, the timely payment of all fees.
a. Renewal. Unless terminated as set forth herein, at the expiration of the initial term (and each succeeding term), the Agreement will automatically renew for successive one (1) month terms.
b. Termination by Practice. Practice shall have the absolute and unconditional right to terminate the Agreement at any time, with or without cause. Any unused portion of any Fees already paid to Practice prior to date of termination shall be refunded to Patient, according to schedule set forth by Practice.
c. Termination by Patient. Patient shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination, upon giving thirty (30) days prior notice to the Practice. Termination shall be effective at the conclusion of the Term during which such notice period expires. Provided, however, termination shall not relieve Patient of any obligations, including without limitation, Fees, owed to Practice up to and including the effective date of termination. Following termination, Patient shall not be eligible to rejoin the Practice for a period of sixty (60) days from the effective date. Patient will also be subject to a two hundred dollar ($200) reenrollment fee upon rejoining.
7. Severability. If for any reason any provision of this 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 that provision shall then be enforceable.
8. Amendment. This Agreement may be unilaterally amended at Practice’s sole discretion and/or to the extent required by federal, state, or local law or regulation (“Applicable Law”) by providing notice to Patient within thirty (30) days of such amendment. Any such changes are incorporated by reference into this Agreement without the need for signature by the parties and are effective as of the date established by Practice. Moreover, if Applicable Law requires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been expressly set forth in this Agreement.
9. Relationship of Parties. The parties intend and agree that Practice (including its physicians and staff), in performing Services under this Agreement, shall be 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 shall have exclusive control of all work and the manner in which it is performed.
10. Legal Significance. Patient acknowledges that this Agreement is a legal document and creates certain rights and responsibilities. Patient 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.
11. Miscellaneous. This Agreement, and any rights the Patient may have under it, may not be assigned or transferred by Patient. This Agreement may be assigned by Practice. This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted. Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text. This Agreement contains the entire agreement between the parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement. This Agreement shall be governed and construed under the laws of the State of Indiana and all disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for the Practice’s address. All written notices are deemed served if sent to the address of the party by first class U.S. mail. The parties have signed duplicate counterparts of this Agreement on the date first written.
I, the Patient, expressly consent to FISHERS DIRECT FAMILY CARE LLC, AND/OR ITS PHYSICIANS, STAFF, EMPLOYEES, AGENTS AND REPRESENTATIVES, SHARING MY CONFIDENTIAL PERSONAL HEALTH INFORMATION WITH OTHER TREATING PHYSICIANS, HOSPITALS, HEALTHCARE FACILITIES, AND LICENSED HEALTHCARE PRACTITIONERS. I ALSO AGREE TO THE PRIVACY PRACTICES OF CROSSWIND PHARMACY WHICH MAY BE USED FOR PRESCRIPTION MEDICATIONS. THE AGREEMENT IS AVAILABLE UPON REQUEST.
TO ENJOY THE CONVENIENCE OF AUTOMATED BILLING, I UNDERSTAND THAT I WILL BE ENROLLED IN AN AUTO-DEDUCTION PAYMENT PLAN, AND I AUTHORIZE FISHERS DIRECT FAMILY CARE LLC, AND/OR ITS SERVICE PROVIDERS, TO AUTOMATICALLY BILL THE CARD PROVIDED TO PAY ALL FEES UNDER THIS AGREEMENT.