Member Service Agreement
Effective January 1, 2018
This Member Services Agreement (“Agreement”) is made by and between First DPC Ventures, LP, (herein after called ‘First Primary Care’) a member services organization and the Patient, or Patient’s legal representative, or guardian (“Member”). To provide the Member Services to Members, First Primary Care contracts with Our Way Health PLLC (“OWH”) to provide comprehensive primary care for it’s members. OWH is a Texas Professional Limited Liability Company that employs or contracts with licensed medical practitioners (“Provider or Providers”). First Primary Care shares common ownership with Our Way Health. From time to time, First Primary Care may contract with other third-party medical providers such as; Lucent MD and Green Imaging to provide certain Member Services that are outside the scope of OWH.
This Agreement is subject to the Texas Occupations Code, Title 3. Health Professions, Subtitle B. Physicians, Chapter 162. Regulation of the Practice of Medicine, Subchapter F. Direct Primary Care. Any disputes arising from this Agreement shall be governed by Texas law.
This Agreement is entered by mutual voluntary consent.
First Primary Care is a Member Services Organization contracting with various medical providers including OWH specializing in primary care both in office and via electronic communication. In exchange for the consideration set forth in the Membership Agreement the Parties agree as follows:
Term, Cancellation, Renewal
Member understands that by signing below, Member agrees to become a member of FPC and patient of OWH and it’s Medical Providers, who provide Direct Primary Care medical services in exchange for a monthly membership fee (“Services and Membership Fees” defined below) for the Term (defined in Section 2 herein) of this Agreement.
Term & Billing
The Term of this Agreement shall be month to month, and shall automatically renew monthly, unless Member terminates the Agreement by giving advance thirty (30) days notice in writing to FPC. Member understands that a nonrefundable Enrollment Fee may be due upon registration. Member understands and agrees to pay the monthly Membership Fee each month by the due date, via automatic debit or credit transaction using the payment information on file with FPC. Member acknowledges that a transaction declined due to insufficient funds or an expired debit or credit card may result in an additional fee of fifty-dollars for each late or missing payment ($50.00).
Any failure to comply with the terms set forth in this Section will result in termination of this Agreement and membership with FPC. By signing for Membership Services, the Member hereby authorizes FPC to initiate monthly charges to his/her credit card, debit card, or bank account for the Membership Fee plus any additional incidental costs incurred by the Member or FPC on the Member’s behalf since the previous billing date. Member understands that his/her membership with FPC is continuous and that, by signing below he/she authorizes recurring credit/debit or bank account charges.
Member acknowledges that FPC and Member each have an absolute and unconditional right to terminate this Agreement at any time and for any reason. Member shall be required to give advance thirty (30) days notice in writing to First Primary Care in order for a termination to be effective. Upon termination, both Parties shall be released of all obligations under this Agreement, except that Member shall remain responsible for any outstanding membership, service, or other fees of any type due prior to or incurred as a consequence of Member’s termination. FPC shall be entitled to all amounts paid by Member, and is not required to provide any pro-rated refunds or refunds of any type.
This type of Direct Primary Care practice depends on membership fees to cover practice costs and staff and physician salaries. If Member cancels and wishes to renew, a new Membership Agreement must be executed and Member shall be subject to any applicable increase in fees and/or enrollment fees. Repeat cancellations and renewals are discouraged. Members should note that the patient panels are limited in size and may be full, thus prohibiting their ability to re-enroll with the same care team. FPC reserves the right to deny renewal or re-enrollment of any Member at any time, for any reason.
Member understands that FPC provides a limited and specific set of services which are generally within the scope of the practice of general family medicine. Member acknowledges that FPC’s ability to provide care may be limited by training, experience, equipment and supplies, and other unforeseen circumstances that are beyond the scope or control of FPC.
Member understands that OWH Providers may be unavailable at times due to patient care, personal illness, injury, emergencies, or other obligations. OWH will make reasonable attempts to provide alternative coverage in the event of absence. OWH may use other physicians, nurse practitioners, physician assistants, nurses, medical assistants, and other staff to assist in providing care, consistent with their training, qualifications, and licensure. All such personnel will be bound by this Membership Agreement.
In exchange for the monthly Membership Fee described below, Members shall be entitled to receive the following services: Essential Office Visits (well-child checks; sick visits; school, sports, camp and job specific physicals; routine gynecological care; and annual exams) with no-copays or additional per-visit fees; A comprehensive medical and wellness assessment; Chronic disease management, advice and counseling, prescribing of medications; In-office procedures and urgent care for acute minor illnesses or injuries (we cannot guarantee urgent care availability. Patients acknowledge and understand that some conditions will require evaluation in the emergency department of a hospital or other licensed emergency facility); and communication with providers by phone, video, e-mail, text, and other methods as deemed appropriate. All services, tests, and procedures shall be performed when reasonable and necessary in Provider’s sole discretion. Additional fees or costs will apply for related medical goods and services, however every effort will be made to keep those fees and costs to a minimum.
The following (non-exhaustive) list of medical services are not covered by the monthly Membership Fee. FPC will assist Member to obtain any of them, as needed, at special reduced pricing: X-rays, CT scans, ultrasound; outside office blood/other lab tests, even though some samples will be drawn in the office at no charge; Any surgery or procedure not able to be performed in the FPC practice location (e.g. in a hospital, surgery center or specialist’s office); The cost of immunization drugs; Obstetrical care and delivery; Durable medical equipment and supplies (e.g. crutches, wheelchairs, walkers, canes, walking boots, casts, etc.); Prescription medications; and Intravenous, injectable or oral medication.
Costs Outside Of The Scope Of Agreement
The Member shall be able to secure many of the above ‘non-covered services’ at reduced prices or fees when coordinated through their FPC Member care team. All pricing is transparent, and your costs will be made clear prior to providing any non-covered good or service.
Not a health insurance substitute. Member recognizes that this agreement and the membership described herein is not health insurance or a substitute for health insurance
Member acknowledges and agrees that from time to time a Member may require medical services which is beyond the scope of FPC, OWH and this Membership Agreeement (e.g. hospitalization, surgeries, specialist consults, etc.). Member understands and acknowledges that First Primary Care and OWH have specifically recommended (but not required) that each Member secure major medical health insurance, a medical cost sharing plan, or some other appropriate form of payment to mitigate the potentially catastrophic financial risks of medical emergencies, injuries and acute and chronic illnesses and diseases.
No Federal Funds or Insurance
Member understands that under no circumstances will FPC or OWH bill Medicare, Medicaid, or any other insurance for Medical services rendered under this Agreement. Member acknowledges and understands that the Member is solely responsible for insuring payment and or seeking reimbursement for any medical services provided by any other entity.
Not Medicare Eligible
Member hereby certifies that Member will notify FPC within ten (10) business days when Member becomes eligible for, or covered by, Medicare. Member understand and agrees that neither FPC nor any of it’s Provider’s will bill Medicare for any services whatsoever.
Member acknowledges that this Agreement requires the ongoing payment of a monthly Membership Fee. Continuous Membership is dependent on timely payment of this Membership Fee; and Member agrees and acknowledges that Membership Fees that are sixty (60) days past-due will result in the termination of this Membership Agreement and accordingly all services hereunder shall terminate as of the Termination date.
Changes In Fees
The amount of the monthly Membership Fee may be changed at any time by FPC with ninety (90) days prior notice. As always, the Member may cancel at any time subject to the termination terms of this Agreement if they are dissatisfied for any reason at all. Membership Fees paid prior to the date of notice of termination are non-refundable. The Membership Fee schedule is set out at www.firstprimarycare.com and is included in this Agreement by reference.
The Member’s clinic address, phone number, and days and hours of operation are set out at www.firstprimarycare.com. Office visits are by appointment only, but a brief phone call or text can secure a timely appointment.
Responding To Member
Phone calls to FPC will be answered by a live person whenever possible. Our medical professionals will make every effort to respond to Member’s inquiries as quickly as possible. Electronic correspondence (email, or Texts) from a Member will receive a response within 24 hours. If for any reason a Member does not receive a response within 24 hours, the member should make a phone call or use another form of communication.
Communications, Privacy, HIPAA
We respect and value Member’s privacy. FPC makes every reasonable effort to keep Member’s personal information and medical records private and secure, within the bounds of applicable laws. Communication by phone, e-mail, text messaging and via other methods offer great convenience and portability. We must point out and Members must acknowledge however, that such communications are not reliably secure; even with the latest precautions, these communications come with some risk of lost information or privacy. Member acknowledges that Member has read and understood FPC’s Notice of Privacy Practices, and that Member may access it at any time at www.Firstprimarycare.com. Member has had time to consider which method(s) of communication Member prefers, and member has made Member’s preferences known to FPC through the “preferred/acceptable modes of communication” portion of the new patient enrollment form. Member understands that e-mail and other electronic forms of communication are not appropriate for emergencies, or other time-sensitive matters, or for communication of highly personal or sensitive information.
IMPORTANT: In the event of a medical emergency or situation that Member could reasonably expect to develop into an emergency, the Member agrees to call 911 or promptly seek care in an emergency room. Members should never rely on FPC or its Medical Providers to address an emergency medical situation.
Member agrees to hold FPC, OWH and it’s Providers harmless against any claims of liability or any loss, injury, damages or expenses that occur due to circumstances beyond FPC’s direct control or related to technical failure with the FPC website, email, or other electronic services, including but not limited to: power outages, faulty cellular, cable, or Wi-Fi service, failure due to internet service provider caused outages, failure to properly address e-mail messages, interception of communications by a third party, or Member’s failure to follow FPC’s recommendations regarding electronic communications.
Member agrees not to hold FPC, OWH or any of it’s Medical Providers liable for any loss, injury, damages or expenses beyond OWH’s control related to technical failure of the OWH website, email, or other electronic services, including but not limited to: power outages, faulty cellular, cable, or Wi-Fi service, failure due to internet service providercaused outages, failure to properly address e-mail messages, interception of communications by a third party, or Member’s failure to follow OWH’s recommendations regarding electronic communications in this Agreement.
Member agrees that this Agreement represents the entire agreement between the parties. No other oral or written agreements or promises exist between the parties to this Agreement.
This Agreement will be construed in accordance with and governed by the laws of the State of Texas.
- This Agreement is expressly limited to routine primary care services, and is NOT a medical insurance contract.
- Member acknowledges that Member does NOT have an emergency medical problem at this time.
- Member does NOT expect FPC to file or contest any third party insurance claims on his/her behalf.
- Member is voluntarily enrolling himself/herself (and/or family/dependents or employees, if applicable) as a Member.
By signing this Agreement Member acknowledges he/she has read this Agreement in full and agrees to all of the terms and conditions set forth herein. Member represents they have authority and capacity to enter into and abide by this agreement.