CHICO DIRECT CARE DIRECT+CARE MEMBERSHIP AGREEMENT This DIRECT+CARE Membership Agreement (the “Agreement”) specifies the terms and conditions under which you (the “Member”) and your spouse/partner or dependents included in the Agreement will participate in the benefits available under the agreement. 1. This Agreement is between Chico Direct Care and ______________________________________ (Primary Member), and includes the following person(s) listed below (attach additional sheets if necessary): Name: DOB: Relationship: ________________________ Name: DOB: Relationship: ________________________ Name: DOB: Relationship: ________________________ Name: DOB: Relationship: ________________________ 2. This is a month-to-month agreement. Either party may terminate this agreement for any reason provided they provide written notice 30 days in advance. The term of this Agreement is for one year, beginning on the day your first payment is processed and signed contract has been received. The Agreement shall automatically renew for successive one-year periods unless either party cancels the Agreement in writing. 3. This Agreement is not a health insurance policy. This Agreement includes only the specific services as outlined in Section 20 below, and does not include any major catastrophic medical care provided by emergency rooms, hospitals, urgent care centers, services rendered by specialists or specialty clinics, or other entities not outlined specifically as a participating clinic. 4. Adult Members participating in the Agreement may sign up a spouse, partner, or dependents under this Agreement. Others outside of that relationship wishing to join as Members must have their own separate Agreement. 5. At the date of this Agreement, membership fees are as follows: 2233 Nord Ave. Suite 1. Chico, CA 95926
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CHICO DIRECT CARE DIRECT+CARE MEMBERSHIP AGREEMENT
This DIRECT+CARE Membership Agreement (the “Agreement”) specifies the terms and conditions under which you (the “Member”) and your spouse/partner or dependents included in the Agreement will participate in the benefits available under the agreement.
1. This Agreement is between Chico Direct Care and ______________________________________ (Primary Member), and includes the following person(s) listed below (attach additional sheets if necessary):
Name: DOB: Relationship: ________________________
Name: DOB: Relationship: ________________________
Name: DOB: Relationship: ________________________
Name: DOB: Relationship: ________________________
2. This is a month-to-month agreement. Either party may terminate this agreement for any reason provided they provide written notice 30 days in advance. The term of this Agreement is for one year, beginning on the day your first payment is processed and signed contract has been received. The Agreement shall automatically renew for successive one-year periods unless either party cancels the Agreement in writing.
3. This Agreement is not a health insurance policy. This Agreement includes only the specific services as outlined in Section 20 below, and does not include any major catastrophic medical care provided by emergency rooms, hospitals, urgent care centers, services rendered by specialists or specialty clinics, or other entities not outlined specifically as a participating clinic.
4. Adult Members participating in the Agreement may sign up a spouse, partner, or dependents under this Agreement. Others outside of that relationship wishing to join as Members must have their own separate Agreement.
5. At the date of this Agreement, membership fees are as follows:
6. Members will also be charged a one-time enrollment fee of $25 per individual, at the time of enrollment. This enrollment fee is non-refundable if this Agreement is terminated.
7. Annually, Direct+Care accepts fees by cash, check, debit card, automatic bank debit (ACH authorization), or credit card. There is a 10% discount for paying an individual, couple, or family’s annual membership in advance. We will contact you at the end of your 12 month subscription to verify how you would like to pay for the following year.
8. Monthly, Direct+Care accepts fees by automatic bank debit (ACH authorization) or a credit card on file. If paying in monthly installments, your initial charge will include the enrollment fee and first month’s dues. Fees are automatically collected within 2-4 days of your enrollment day on a monthly basis. For example, if your membership beings June 30, 2017, you will be billed towards the end of July 2017 for your second month’s fees.
9. Member shall update credit card, debit card, or banking information when necessary and in a timely manner, and will be responsible for any amounts owed to Chico Direct Care regardless of whether the account or card is expired, cancelled, or otherwise not accepted for payment. Member(s) agree to pay a $25 charge for a returned payment.
10. This Agreement authorizes Chico Direct Care to keep credit card, debit card, or banking information on file, and to charge the Member’s applicable account for monthly fees without requiring Chico Direct Care to obtain written authorization for each new charge.
11. Member(s) understands that all Members included in this Agreement will not be scheduled for a Member appointment unless the membership fees have been paid up through or beyond the date of the desired appointment.
12. Under the Direct+Care plan, Members are entitled to direct access to their doctor 24/7, 365 days a year. This includes: texts, emails, phone calls, teleconferencing, and in-person visits. If an in-person visit is deemed necessary by Dr. Villasenor, a same day or next day appointment is guaranteed by Chico Direct Care.
13. Members shall use their communications with Chico Direct Care solely for their own health issues, and not that of their friends and family (unless said family members are Direct+Care members). Chico Direct Care trusts that it’s members will not abuse access granted as Direct+Care Members.
14. If Dr. Villasenor of Chico Direct Care is sick, out of town, or experiencing a family emergency, he will do his best to answer emails, text messages and phone calls for Members. In the event the Member needs to be seen in person, there will be a local practitioner on call in Chico.
15. Member(s) understands that Chico Direct Care may add or decrease services to its Direct+Care plan, participating providers, and participating clinics, or increase membership fees at any time. In the event of such changes, Chico Direct Care will provide notice to Member(s) at least 60 days before the change.
16. Member(s) understands that there may be additional charges for equipment, laboratory, or other services that are ordered through outside entities or providers as a result of care given by a participating clinic or provider. This Agreement does not cover additional charges for such items. Only the services specifically outlined below in Section 20 are covered by the membership fees. If a participating clinic or provider renders services beyond the scope of this Agreement, there will be added charges. Member(s) agree to pay for these additional charges at the time of service. If additional charges are not paid at the time of service, Member(s) agree to allow Chico Direct Care to charge the Member(s) account(s) on file for those amounts.
17. Member(s) also covered under Medicaid or other health insurance plans with which participating providers are contracted, agree(s) not to seek reimbursement from their insurance plan for services received under this Agreement. Chico Direct Care will not file an insurance claim for Member(s), and Member(s) also agree not to file an insurance claim.
18. Members agree not to bill Medicare or attempt to obtain Medicare reimbursement for any services provided to them as Direct+Plan Members. If the Member is eligible for Medicare, or becomes eligible during the term of this Agreement, then s/he will sign the Medicare Opt Out and Waiver Agreement attached to this Agreement. The Member shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law.
2233 Nord Ave. Suite 1.
Chico, CA 95926
19. Chico Direct Care reserves the right to refuse membership to its Direct+Care plan to any person for any reason.
20. Services Included in Direct+Care Membership:
a. ACUTE CARE: Coughs, colds, flu, sprains, sinus and ear infections, sore throat, fever, rashes, diarrhea, back pain, strep tests, asthma, bronchitis, pneumonia, kidney and bladder infections. Other conditions as deemed applicable by Physician.
b. ANNUAL PHYSICALS: School, Athletic, Adult, Well-Child, Well-Women, Well-Men
c. BASIC ANNUAL LABS: Comprehensive Cholesterol Panel, Basic Metabolic Panel, HbAiC, Complete Blood Count. At least once a year.
d. PREVENTATIVE MEDICINE: Electrocardiograms, vision screening, BMI analysis, nutrition counseling, Flu shot, Tdap, routine well child vaccinations
e. MINOR SURGERIES: Wound care, minor laceration repair, wart destruction, simple lypoma removal
f. PROCEDURES, TEST AND TREATMENTS: In-house rapid strep and flu tests, TB Test, EKG, nebulizer breathing treat, abscess draining, foreign body removal, trigger point injections, urinalysis, simple biopsy, cryotherapy (warts), simple sutures, joint injection, antibiotic injection, ear lavage, and seasonal allergy treatments.
g. MEN’S AND WOMEN’S HEALTH: Well-man and well-woman screenings, cancer prevention, pre-conception health, perimenopausal and postmenopausal health. Gynecology, including necessary paps, can be provided by a female provider in Chico at no extra charge, if you prefer.
h. PEDIATRICS: Well-child evaluations, acute care as listed above, development evaluations
i. CHRONIC THERAPY: Diabetes, arthritis, acid reflux, high blood pressure, high cholesterol, cardiovascular disease, chronic fatigue, fibromyalgia, asthma, COPD, general pain management, low back pain
j. ADMINISTRATION TASKS: Referrals, Pre-Operative Forms, Medication Refills
21. Member(s) understand(s) that charges for items not covered by the membership must be paid at the time of service, and will not be billed through the Member(s) monthly membership dues agreement. Those items available for an additional fee are as follows: Any lab test not included above, lab tests done by Quest, Valley Clinical Laboratory, or any other laboratory facility. Immunizations not included above and any other ancillary service provided by another entity, regardless of whether their service is provided elsewhere or at the participating clinic.
22. The Member acknowledges that although Chico Direct Care shall comply with all HIPAA privacy requirements, communications with Chico Direct Care using e-mail, facsimile, video conferencing, cell phone, texting, and other forms of electronic communication can never be absolutely guaranteed to be secure or confidential methods of communications for Protected Health Information (PHI). As such, Member expressly waives the Physician’s obligation to guarantee confidentiality with respect to the above means of communication. Member further acknowledges that all such communications may become a part of the medical record. By providing an e-mail address to Chico Direct Care, Member authorizes Chico Direct Care and its Physicians to communicate with him/her by e-mail regarding the Member’s PHI. The Member further acknowledges that:
a. Although the Physician will make all reasonable efforts to keep e-mail communications confidential and secure, neither Chico Direct Care, nor the Physician can assure or guarantee the absolute confidentiality of e-mail communications.
b. At the discretion of the Physician, e-mail communications may be made a part of Member’s permanent medical record.
2233 Nord Ave. Suite 1.
Chico, CA 95926
c. You understand and agree that e-mail is not an appropriate means of communication in an emergency, for time-sensitive problems. In an emergency, or a situation that you could reasonably expect to develop into an emergency, you understand and agree to call 911 or the nearest Emergency room, and follow the directions of emergency personnel.
d. Email Usage. If you do not receive a response to an e-mail message within 24 hours, You agree that you will contact the Physician by telephone or other means.
e. Technical Failure. Neither the Chico Direct Care, nor the Physician will be liable for any loss, injury, or expense arising from a delay in responding to Patient, when that delay is caused by technical failure. Examples of technical failures (i) failures caused by an internet service provider, (ii) power outages, (iii) failure of electronic messaging software, or e-mail provider (iv) failure of the Chico Direct Care’s computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of email communications by a third party which is unauthorized by the Chico Direct Care; or (v) Member failure to comply with the guidelines for use of e-mail described in this Agreement.
23. Member(s) understands that the monthly membership fees required under this contract do not apply towards any health insurance plan deductible. Furthermore, membership under this contact does not by itself fulfill the personal health insurance mandate under the Affordable Care Act. Member(s) also understand that Chico Direct Care makes no representations regarding the tax implications of membership in this agreement. Member(s) are encouraged to seek the advice of a competent tax professional for advice regarding any related tax issues.
24. This Agreement is not complete and binding unless the Member(s) also signs the Automatic Payment or Credit Card Authorization and any other patient related forms required by the entities providing care under this agreement. Those documents are hereby incorporated into this contract by this reference.
25. This Agreement contains the entire agreement between the parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement. Please contact Dr. Villasenor at, [email protected] with any questions you may have before signing.
