Establishment as a Patient
A person is considered an active member (established as a patient) in the practice when the following conditions are met:
1. They (or their family representative) have paid the registration fee, have signed the terms and conditions (this document), and have sent in the registration forms.
2. They (or their family representative) have come to the office for an appointment.
3. They (or their family representative) have signed the practice fee calculation agreement and paid the first monthly payment.
A family unit is defined as the members of a single household who are under direct care of the head of that household. This includes
· Head of household
· Children, biological or those under the guardianship of the head of household and/or spouse.
· Children away at college/other school who are still considered members of the household unit.
Family unit (unless otherwise agreed to by the practice) does not include
· Grandparents or parents of the head of household
· Non-family members living with the family
· Family members living at another residence.
The following services are offered by the practice to its active members:
· Office visits – up to 8 per individual member per month at no charge.
· Office procedures/labs
o Those contained on the list (see Appendix 1) of covered procedures are performed at no charge
o Those on the discounted list are charged at the price listed (unless charged to insurance)
o Those not on either list are charged at the price given to the patient at the time of the procedure.
· Phone/Email/Messaging – Care is given at no charge to the patient using communication tools.
· Coordination of care/record keeping – The practice works to coordinate care with the member and with other physicians, and also works to minimize those visits whenever possible.
· After-hours care – The practice provides appropriate care after-hours, including answering phone calls and secure messages as needed.
Regarding hospital care
The practice does not provide care directly to patients while they are admitted to the hospital, but coordination of care can continue. Discussions between patients, family members, and hospital caretakers, with the practice staff regarding the care in the hospital are encouraged. In fact, we expect people admitted to the hospital to call us so we can help during this time.
Fees and Payment
Fees fall under three categories: Registration Fees, Monthly Subscription Fees, and Service Fees.
1. Registration Fee
Registration fee is a $60 fee paid at the beginning of membership for every member. This payment comes along with the completion of the initial documents (for new members) and with filling out updated information (for returning members). Should a membership lapse or be terminated, the registration fee must be paid again for membership to become active.
2. Monthly Subscription Fee
The monthly subscription fee depends on the age(s) of the member(s) in a family/household unit:
· Age 0-2: $40 per month
· Age 3-18: $30 per month
· Age 19-39: $35 per month
· Age 30-49: $45 per month
· Age 50-64: $55 per month
· Age 65 and up: $65 per month
· Family Fee (up to 5 family members) $160 per month
Additional family members after the 5th are an additional $10 per month.
A student who is away at college (who is not head of a household) is discounted to $10 per month while they are enrolled at schools outside of the local area.
3. Service Fees
Service fees include fees for services outside of those covered by the monthly payment. These include:
· Lab tests sent out to the local lab, which are not billed to insurance.
· In-office tests/procedures not covered by the monthly payment.
· Other services outside the list of covered services.
Payment for these procedures is expected at the time they are performed. The member gives the practice permission to send charges to the credit card/bank account on file.
Payment of Monthly Fees
· The practice requests that members set up recurrent billing via automatic draft from credit/debit card or funds transfer from a bank account to ensure that payment is on time.
· Those who choose to not set up automatic draft/funds transfer will be expected to pay the first two months' monthly fees at the time of the first visit. Those who set up this payment will start recurrent billing on the day of their first visit.
· Those requesting the ability to be invoiced each month are expected to pay that invoice within 7 days of the date of billing or incur a $10 late fee.
· Credit/Debit card payments that are denied or rejected will incur a $10 processing fee.
· Failure to make a payment within 30 days of the due date will cause membership to be suspended, with services not being given by the practice until all owed payments are received.
· Failure to make a payment within 60 days of the due date will cause membership to be terminated. To re-join the practice, the member goes to the end of any waiting list that exists, must come to the office and sign agreements again, and will be required to pay both the registration fee and two month’s monthly fees before resuming as an active patient.
Termination of the agreement between members and the practice can occur either by the member or the practice in the following circumstances:
1. The member/patient requests in writing (email is acceptable) that the relationship be terminated.
2. The practice informs the member/patient in writing that the relationship is terminated.
3. The member/patient becomes more than 60 days delinquent on the account (as listed above).
 A $50 fee will be required for each 30-minute office visit during a calendar month in which the member has already been seen 8 times.
 Effective 6/1/2014. Established patients will remain at previous prices as long as they remain active patients in the practice.