Note: Signing this Membership Agreement may alter your legal rights under Maryland Law. Please read entire document carefully before signing.
I, the undersigned, wish to receive primary care medical services from Evolve Direct Primary Care (the “Practice”)and its practitioners (each, a “Practitioner”). A list of the current Practitioners is included at the end of Attachment B. I understand these medical services are offered subject to the following terms and conditions:
- Effective/Renewal Date. This Patient Agreement (the “Agreement”) shall begin on _________ (the “Effective Date”) and continue as long as I continue paying the Membership Fee described below and subject to termination as described below. This Agreement supersedes any prior Patient Agreement(s) I have signed with the Practice.
- Initiation Fee.I understand that I must pay a one-time $50 (fifty dollar) initiation fee upon joining the Practice. Members that have previously canceled their membership and wish to re-enroll will also be subject to a $50 (fifty dollar) initiation fee.
- Services. I understand that the Practice will make available (a) certain medical services as requested by me or as deemed necessary by the Practitionersin accordance with the established standard of care for primary care practitioners and (b) certain related services (such medical services and related services are referred to in this Agreement collectively as “Services” and described in further detail in Attachment A).
- Membership Fee. I understand that I must pay a monthly membership fee (the “Membership Fee”) in order to receive Services from the Practice. Certain Services are included in the Membership Fee but all other Services I receive from the Practice will be charged separately at the time of service according to the Practice’s current Member Fee Schedule. Attachment Alists all Services included in the Membership Fee, all other Services available from the Practice, and the Practice’s current Member Fee Schedule. Attachment Aalso lists the current Membership Fee and describes how payment must be made. The Practice may change its Member Fee Schedule and the Membership Fee at any time upon ninety (90) days’ prior written notice to me.
- Private Contract with Medicare Beneficiaries: If I am a Medicare Part B beneficiary, I also agree to the terms listed in Attachment B, and will sign Attachment Bin addition to this Agreement to confirm my acceptance of those terms.
- Non-Participation in Medicare and Private Insurance Plans. I understand that the Practice and the Practitioners do not participate or contract with Medicare or any insurance plans, including, but not limited to, Health Maintenance Organizations (HMOs), Point of Service Plans (POSs), Preferred Provider Organizations (PPOs) and Preferred Provider Networks (PPNs), and that all Practitioners are opted out of the Medicare program. I therefore acknowledge that, if the Practice provides Services to me: (a) the Practice, and not Medicare or my insurance plan, will bill me directly for those Services at its applicable rates, (b) payment for such Services is due at the time the services are rendered, and (c) I, instead of Medicare or my insurance plan, will be fully and personally responsible for paying for those Services. I further acknowledge that it is my responsibility to understand the limitations of my insurance coverage and I will not hold the Practice responsible for any denied payment for services by my insurance plan caused by my entering into this Agreement. I understand that I may, at any point, elect to obtain Services from a health care provider who does participate with my insurance plan rather than getting treatment from the Practice, and that if I obtain Services from such other health care provider, more favorable reimbursement may be available to me.
- Submission of Insurance Claims. I understand that the Practice will NOTsubmit any claims for Services to my insurance plan on my behalf, and that I am solely responsible for submitting such claims if I choose to seek reimbursement from my insurance plan for such Services. I also understand that any reimbursement by my insurance plan will be sent directly to me. If the Practice is mistakenly reimbursed by my insurance plan, then the Practice will return the check to my insurance plan. I understand that my insurance plan may not pay at all for some Services provided by the Practice, and may only make a partial payment for other Services provided by the Practice. I further understand that the Practice makes no representations or promises regarding the amount of payment to be received for any claim(s) I may submit to my insurance plan. Medicare and HMOs do NOT permit me to submit claims for Services provided by the Practice, and I agree not to submit a claim for any such services to Medicare or any HMO.
- Termination of this Agreement.
- Termination by Patient:
- I understand that I may cancel this Agreement at any time after the first 180 days by sending the Practice written notice (a) stating that I wish to cease using the Practice for my medical services and (b) requesting that a copy of my medical records be sent to either another physician or directly to me. Please note a minimum of 3 business daysprocessing time is necessary to effect the cancellation.
- Patient understands that after cancellation, the Practice will no longer be able to prescribe or continue any prescriptions which Patient may have been receiving on a long term basis and it is further stated that Patient should already have met and transferred his/her care to her new Primary Care provider PRIOR to cancellation to minimize any gap in medical attention.
- If patient wishes to terminate the contract prior to 6 months for any reason, patient agrees to pay, and authorizes payment using credit card or bank account on file, to the Practice of any remaining balance as well as authorizations to collect the any of the remaining 6 months of membership at the time of the cancelation.
- Termination by Practice:
- The Practice may also terminate this Agreement and the physician-patient relationship with me upon thirty (30) days’ prior written notice if any Membership Fee payment is more than fifteen (15) days late and at any other time upon ninety (90) days’ prior written notice; in such case, the Practice will provide me with information to assist me in finding another primary care physician to take over my care.
Membership Fee Schedule is age based as shown below:
- Membership Fee and Payment Method (as of September 1, 2018).
- Monthly fee, payable by automatic deduction from credit card or bank account on file.
- Patients must sign credit card authorization when Patient Agreement is signed and before any Services are provided.
- If patient does not wish to use a credit card or bank accountant for automatic monthly payment, payments can be made once every 6 months for the following 6 months. For instance, when signing up, payment for the first 6 months will due prior to first visit then every 6 months thereafter.
Patient Name: ______________________________________________
Patient Signature: ___________________________________________ Date: _______________
Evolve Direct Primary Care:
Signed by: Michael R. Freedman, MD
Signature: _______________________________________ Date:_______________
If the Patient is a minor,the Patient’s parent or legal guardian must sign below indicating the parent or guardian’s acceptance of the above terms and agreement to pay the Membership Fee on behalf of the Patient:
Name of Parent or Legal Guardian: _______________________________________________________
Signature of Parent or Legal Guardian: ______________________Date: _________________
ATTACHMENT A – SERVICES AND MEMBER FEE SCHEDULE
Services Covered Under Membership Fee
ATTACHMENT A – SERVICES AND MEMBER FEE SCHEDULE
Services Billed Separately and Member Fee Schedule (as of September 1, 2018)
ATTACHMENT B –
MEDICARE OPT-OUT AND LIST OF PRACTITIONERS
I AGREE, UNDERSTAND AND EXPRESSLY ACKNOWLEDGE THE FOLLOWING:
- The Practitioners listed below (the “Practitioners”) have all opted out of the Medicare programeffective on dates indicated after their names for a period of at least two years.
- Neither the Practice nor any Practitioner is involuntarily excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.
- I accept full responsibility for payment of the Practice’s and Practitioners’ charges for all items and services furnished to me by the Practice.
- Medicare fee limitations do not apply to what the Practice and the Practitioners may charge for the items or services they provide to me.
- I will not submit a claim (or request that the Practice or any Practitioner submit a claim) to the Medicare program for payment for any items or services provided to me by the Practice or any Practitioner, even if the items or services are covered by Medicare Part B.
- Neither the Practice nor any Practitioner will submit a Medicare claim for items or services they furnish to me, and no Medicare reimbursement will be provided for such items or services.
- Medicare payment will not be made for any items or services provided to me by the Practice or any Practitioner even if those items or services would have otherwise been covered by Medicare if I had not signed this Patient Agreement and this Attachment D, and a proper Medicare claim had been submitted.
- I enter into this Patient Agreement with the knowledge that I have the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that I am not compelled to enter into private contracts that apply to other Medicare-covered items and services furnished by other physicians or practitioners who have not opted out of Medicare.
- Medigap plans do not provide payment or reimbursement for items and services (such as any Services provided to me by the Practice or the Practitioners) not paid for by Medicare, and other supplemental plans may likewise deny payment or reimbursement for such items and services.
- I am not currently in an emergency or urgent health care situation, and do not currently require emergency care or urgent health care services.
- A copy of this Patient Agreement with this Attachment B has been provided to me.
Patient Name: ___________________________________________________________________
Patient Signature: __________________________________________Date: _________________
|PRACTIONER NAME||SERVICES||OPT-OUT DATE|
|Michael Freedman, M.D.||Direct patient care||July 1, 2014|
|Deb A. Needle, CRNP||Direct Patient Care||April 1, 2016|
|Megan Leser, MSN, FNP-C||Direct Patient Care||October 1, 2018|