Direct Primary Care Member Agreement
James River Family Medicine
107 13th St N
New Rockford, ND 58356
P: 701-947-2042 / F: 701-947-2041
This Direct Primary Care Patient Agreement (“Agreement”) specifies the terms and conditions under which you, the undersigned patient (“Patient”) may participate in certain private direct health programs identified in the attached Schedule A (“Services”) offered by James River Family Medicine (“Practice”).
SUBSCRIPTION EXPLAINED
Practice’s Services include voluntary subscription offerings that Patient subscribes to in exchange for Patient paying private fees directly to Practice. These Services exceed or are beyond those covered by Patient’s insurance plan. Patient should be aware that in case of emergency, they should report to the nearest Emergency Room for prompt treatment.
SERVICES AND BENEFITS
In exchange for the subscription Program Fees (defined below), Practice will make available to the Patient the Services outlined in Schedule A. Practice reserves the right to update their schedule of Services from time to time, and if it does, it will notify Patient of any changes within thirty (30) days after a change is made and secure Patient’s voluntary consent to any such modification of Services.
PROGRAM FEES
For the Services, the subscribing Patient will pay voluntary subscription fees (“Program Fees”) for the programs selected by Patient from the Services offerings in Schedule A. The Program Fees cover the program Services selected by Patient for a period of six (6) months from the date Patient signs this Agreement, and may be payable on a monthly or annual basis. The Program Fees may increase from time to time with the voluntary consent in advance Patient but will apply to renewal terms. In the event of Program Fees increases, Patient will receive notification in writing and the option of consent to such increase.
Child (Birth – 18): $50/month
Adult (19+): $80/month
Family (2 adults, 3+ children): $250/month
PAYMENT OPTIONS
The Program Fees can be paid with either ACH, credit card, check, or cash.
RENEWALS AND TERMINATION
The Program Fees cover the availability of the Services selected by and subscribed to by Patient for a period of one (1) billing period. Patient will be automatically renewed or enrollment into Practice each month unless Practice received written notice from Patient of withdrawal from Practice thirty (30) days prior to Patient’s renewal date. Failure to pay the renewal Program Fees before the expiration of the prior period may result in termination of enrollment in Practice. Practice is permitted to terminate this Agreement with thirty (30) days’ prior written notice. Patient is permitted to terminate this Agreement with thirty (30) days’ written notice which includes Patient’s reason for termination. Patient will be required to pay any outstanding balance on their account for Services provided and may receive a monthly prorated refund of any unused Program Fees.
EXCLUDED HEALTHCARE SERVICES
The Program Fees cover only the Services subscribed to by Patient. If Practice provides additional services, Patient and Practice may mutually agree upon any additional charges. Patient acknowledges that Patient will be responsible for any additional charges at the time of service. Any charges to Patient for any Services outside of subscription will be at our usual, reasonable and customary rates and consent to in advance by Patient before any such charge is incurred.
TEXT MESSAGING
Should a patient choose to opt out of receiving text messages (non-medical, informative, marketing, scheduling), they shall opt-out on the Patient Portal OR notify the clinic and sign the clinics opt-out ePHI form.
EMAIL COMMUNICATION
If Patient wishes to communicate through email with Practice, Practice will take steps to keep Patient’s communications confidential and secure. Patient acknowledges and understands that email is not a good medium for urgent or time-sensitive communications. In the event that the communication is time sensitive, patient must communicate with Practice by telephone (call or text message), or in person.
APPOINTMENTS AND SCHEDULING
Appointments with Practice are scheduled through Practice office or Patient Portal to ensure amply time is given to each Patient. If Patient has an urgent concern, Patient shall call/text message Practice office and Patient will be given an appointment that will accommodate the urgency. The Practice patient schedule is organized in such a way that it provides and protects extensive time for each Patient. Walk-ins are accepted if it is conducive to the thoughtfully planned schedule.
VACATIONS AND ILLNESS FOR PRACTICE PROVIDERS
Patient acknowledges that there may be times that Patient cannot contact a Practice provider due to the provider’s vacation or illness, or due to technical defects with either Patient’s or Practice’s electronic communication equipment. Patient acknowledges that, should a Practice provider be unavailable, Practice shall make every effort to give advance notice to Patient so that Services can be scheduled on another date.
COMPLIANCE WITH LAW
In establishing the Services programs, Practice intends to do so in compliance with all applicable laws. This Agreement shall be governed by and construed in accordance with the laws of the state in which Practice is licensed and practicing, without application of choice-of-law principles. If there is a change of any law, regulation or rule, federal, state or local, which affects the Agreement of the activities of either Party under the Agreement, or any change in judicial or administrative interpretation of any such law, regulation or rule, this Agreement shall be deemed modified to remain in compliance with such laws.
PRACTICE IS NOT AN INSURER
Practice is not an insurance company and is not promising unlimited care for the Program Fees. Practice presumes that Patient is eligible for healthcare coverage for essential healthcare services not covered by Practice Fee.
AGREEMENT ASSIGNMENT AND MODIFICATIONS
This Agreement may not be assigned to any other person by Patient. This Agreement replaces and supersedes all prior agreements between Patient and Practice. This Agreement may not be modified absent a written signature by Patient and an authorized representative of Practice.
Patient acknowledges that he/she has carefully read this Agreement, was afforded sufficient opportunity to consult with legal counsel of his/her choice and to ask questions and receive satisfactory answers regarding this Agreement, understand his/her respective rights and obligations under it, and signed it of his/her own free will and volition.
By signing below, I am agreeing to enrollment in Practice and the terms of this Agreement as detailed above.