Patient Direct Primary Care Contract
By signing below you are agreeing to participate in the Direct Primary Care Program at Megunticook Family Medicine. This Contract defines both your obligations as well as those of the Practice.
- What the Practice Provides. As an enrollee in the Program, the Practice will provide you with the following services:
- An annual comprehensive health review appointment (“physical”);
- Well and sick care office visits during office hours;
- Administration of some state supplied vaccines and a flu shot (subject to availability).
- Lab tests which can be performed in the office (a list will be provided upon request);
- Availability of a Practice Physician on call 24/7 subject to the limitation below;
- Limitations. The Practice can only provide those services which are within its physicians’ training and capabilities. For example, the Practice will not cover hospital care nor specialty services such as surgery. Lab work or tests which must be completed outside of the office are not included. There may be problems for which the Practice physician determines that consultation or treatment by outside providers is appropriate and you will be responsible to for any associated costs. There may be times when the Practices’ physician(s) are not available due to vacations, illness, etc. or equipment is unavailable and during those times, you may need to seek urgent care elsewhere and you will be responsible for the costs associated with such urgent care services. Opiate addiction treatment with buprenorphine is not included. Prenatal and obstetrical care is not included. Cost of vaccines is not included, except one influenza vaccine (non egg-free) annually. Yellow fever vaccination is not included. Assistance with legal proceedings is not included but can be negotiated separately with your attorney.
- Costs. Your total costs for the above services are as follows:
- A monthly fee as set forth in Appendix 1, payable in advance. You must provide the Practice with a valid bank account routing number or credit card and hereby authorize the Practice to charge the monthly membership fee on the monthly anniversary of enrolling.
- A one time initial registration fee equal to the monthly membership fee.
- A scheduling fee as set forth in Appendix 1, payable at time of service.
- A re-enrollment fee equal to six times the monthly membership fee if a you drop out of the program (or don’t pay the monthly membership fee on time), and then wish to re- enroll. Failure to update invalid credit cards on file will be considered termination by you of participation in the Program.
- Term, Termination. Though this Agreement is for an initial term of one year, either you or the Practice can terminate your participation in the Program at any time by giving at least 30 days’ notice. Any amount prepaid by you beyond those 30 days will be refunded.
- Not Insurance. You recognize that membership in the Program is not insurance and is not intended to replace any existing or future health insurance or health plan coverage that you may carry. It simply gives you access to some medical care for a small scheduling fee. It is not intended to cover all medical care you may ever need. The Practice will not be submitting any of the services to your insurance company for reimbursement. If you need a receipt for services rendered in order to submit your own claim for insurance, the Practice will provide you with this as per Appendix 1. The Practice in no way can assure that you will receive reimbursement from your insurer for such claims.
- Not Participating in Insurance. You acknowledge that the Practice does not participate in any health insurance or HMO plans or panels, and that the Practice does not make any representations whatsoever that any amounts paid under this Contract are covered by your health insurance or other third party payment plans. You retain full and complete responsibility for any such determination.
- Medicare Services. You represent that you are not enrolled in Medicare. This Contract will terminate on the date of Medicare enrollment unless the Practice physician(s) have opted out of Medicare participation. You recognize that the Practice may opt out of participation in Medicare. You are signing this Contract to evidence your understanding and agreement regarding payment for any services to be provided by the Practice. The Practice certifies that neither it nor any of its physicians have been excluded from participation in the Medicare program under Sections 1128, 1156, 1892 or other applicable sections of the Social Security Act. The Practice will certify to you the effective date of opt-out from Medicare when determined and the estimated date of expiration of the opt-out period, provided that the Practice may extend the opt-out period further. By executing this Contract, you acknowledge and agree as follows with respect to all items after that opt-out date:
- You accept full responsibility for payment of the Practices charges for all services furnished by the Practice;
- You understand that Medicare limits do not apply to what the Practice may charge for items or services furnished by the Practice ;
- You agree not to submit a claim to Medicare or to ask the Practice to submit a claim to Medicare;
- You understand that Medicare payment will not be made for any items or services furnished by the Practice that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted;
- You enter into this Contract with the knowledge that you have the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that you are 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;
- You understand that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare;
- You do not currently require emergency care services or urgent care services; and
- You acknowledge that you have been provided a copy of this Contract.
- This agreement is governed by the laws of the State of Maine.
- Any notice that the Practice gives to you can be sent to the address you provide below. Any notice to the Practice shall be sent to Megunticook Family Medicine, PO Box 129, West Rockport ME 04865.
YOU ACKNOWLEDGE THAT YOU HAVE READ THIS CONTRACT AND UNDERSTAND WHAT THE PRACTICE INTENDS TO PROVIDE TO YOU AND WHAT IT WILL NOT PROVIDE. YOU ALSO ACKNOWLEDGE THAT YOU HAVE HAD AN OPPORTUNITY TO ASK ANY QUESTIONS YOU MAY HAVE ABOUT THIS CONTRACT AND THEY HAVE BEEN ANSWERED TO YOUR SATISFACTION.
Dated: ________________________ ___________________________________
Print Name: ___________________________________
Print Address: ___________________________________
______ Plan 1
Monthly fee: Age up to 21 years $25/month, 22-64 years $35/month, 65 and older $50/month
initials () One comprehensive health review appointment (Annual Physical) with no scheduling fee;
() Well and sick care office visits at a scheduling fee rate of $20/visit.
() Lab and other tests which can be performed in the office (a list will be provided upon request);
() Up to two receipts for you to request reimbursement from insurers, additional receipts may be available at a fee rate of $10/visit.
() Availability of a Practice Physician on call 24/7 subject to the limitation below:
There may be short periods where the physician is unavailable for urgent communications. In cases of possible emergency call 911 or equivalent.
List of currently available office tests (subject to change and equipment availability):