Membership Agreement

PATIENT AGREEMENT

FAITH FAMILY MEDICAL SERVICES

This is an Agreement between Faith Family Medical Service, LLC, a Tennessee Legal Liability Company located at 6050 Airline Rd., Ste. 109, Arlington, TN 38002 (Faith Family Medical Services), Amanda Price, FNP (Family Nurse Practitioner) in her capacity as an agent of Faith Family Medical Services and you, (Patient).

Background

The Family Nurse Practitioner (FNP), who specializes in family medicine, delivers care on behalf of Faith Family Medical Services at the address set forth above. In exchange for certain fees paid by You, Faith Family Medical Services its FNP(S), agree to provide the Patient with the Services described in the Agreement on the terms and conditions set forth in this Agreement. 

 Definition

• Patient. A patient is defined as those persons for whom the FNP shall provide Services and who are signatories to, or listed on, the documents attached as Appendix 1, and incorporated by reference, to this Agreement. 

• Services. As used in this Agreement, the term Services shall mean a package of services, both medical and non-medical, and certain amenities (collectively “Services”), which are offered by Faith Family Medical Services and set forth in Appendix 1.

• Terms. This Agreement shall commence on the date signed by the parties below and shall continue for a period of one month, automatically renewed.

• Fees. In exchange for the services described herein, the Patient agrees to pay Faith Family Medical Services the age-tiered amount as set forth in Appendix 1, attached. This fee is payable upon execution of this Agreement and is in payment for the services provided to the Patient during the term of this Agreement and is in payment for the services provided to the Patient during the term of this Agreement. If this Agreement is canceled by either party before the agreement termination date (30 days written notice cancellation), then Faith Family Medical Services shall refund the Patient’s pro-rated share of the original payment, remaining after deducting individual charges for services rendered to Patient up to cancellation. Faith Family Medical Services reserves the right to charge a $150 re-enrollment fee for any previously canceled membership upon requesting re-enrollment. 

• Non-Participation in Insurance. Patient acknowledges that neither Faith Family Medical Services nor the FNP participate in any health insurance or HMO plans or panels and has opted out of Medicare. Neither of the above make any representations whatsoever that any fees paid under this Agreement are covered by your health insurance or other third-party payment plans applicable to the Patient. The Patient shall retain full and complete responsibility for any such determination. If the Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, then Patient will sign the Agreement attached as Appendix 2 and incorporate by reference. This Agreement acknowledges your understanding that the FNP has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for you by the FNP. You agree not to bill Medicare or attempt Medicare reimbursement for any such services. 

• Insurance or Other Medical Coverage. Patient acknowledges and understands that this Agreement is not an insurance plan and not a substitute for health insurance or other health plan coverage (such as membership in an HMO). It will not cover hospital services or any services not personally provided by Faith Family Services or its staff. Patient acknowledges that Faith Family Medical Services has advised that Patient obtain or keep in full force such health insurance policy(ies)or plans that will cover Patient for general healthcare costs. Patient acknowledges that this Agreement is not a contract that provides health insurance, and this Agreement is not intended to replace any existing or future health insurance or health plan coverage that Patient may carry.

• Term; Termination. This Agreement will commence on the date first written above and will extend monthly thereafter. Notwithstanding the above, both Patient and Faith Family Medical Services shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination, upon giving 30 days prior written notice to the other party. Unless previously terminated as set forth above, at the expiration of the initial one-month term (and each succeeding monthly term), the Agreement will automatically renew for successive monthly terms upon the payment of the monthly fee at the end of the contract month.

• Communications. You acknowledge that communications with the FNP using email, facsimile, video chat, texting, and cell phone are not guaranteed to be secure or confidential methods of communications. As such, You expressly waive the FNP’s obligation to guarantee confidentiality with respect to correspondence using such means of communication. You acknowledge that all such communications may become a part of your medical records. By providing Patient’s email address in the attached Appendix 1, Patient authorizes Faith Family Medical Services and its staff to communicate with Patient by email regarding the Patient’s “protected health information” (PHI) (as that term is defined in the Health Insurance Portability and Accountability Act (HIPPA) of 1996 and its implementing regulations) By inserting Patient’s email address in Exhibit 1, Patient acknowledges that:

Email is not necessarily a secure medium for sending or receiving PHI and there is always a possibility that a third party may gain access;

Although the FNP will make all reasonable efforts to keep email communications confidential and secure, neither Faith Family Medical Services nor the FNP can assure or guarantee the absolute confidentiality of email communications;

In the discretion of the FNP, email communications may be made a part of the Patient’s permanent medical record; and,

Patient Understands and agrees the email is not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency or a situation in which the member could reasonably expect to develop into an emergency, Member shall call 911 or the nearest Emergency room and follow the directions of emergency personnel. If Patient does not receive a response to an email message within 24 hours, the Patient agrees to use another means of communication to contact the FNP. 

Neither Faith Family Medical Services nor the FNP will be liable to the Patient for any loss, cost, injury, or expense caused by or resulting from a delay in responding to the Patient as a result of technical failures, including, but not limited to,

• Technical failures attributable to any internet service provider,
• Power outages, failure of any electronic messaging software, or failure to properly address email messages,
• Failure of the Practice’s computers or computer network, faulty telephone or cable data transmission,
• Any interception of email communications by a third party; or
• Your failure to comply with the guidelines regarding the use of email communications set forth in this paragraph.

• Change of Law. If there is a change of any law, regulation, or rule, federal, state or local, which affects the Agreement including these Terms & Conditions, which are incorporated by reference in the Agreement, or the activities of either party under the Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and either party reasonably believes in good faith that the change will have a substantial adverse effect on that party’s rights, obligations or operations associated with the Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms of the Agreement including these Terms & Conditions. If the parties are unable to reach an agreement concerning the modification of the Agreement within forty-five days after of date of the effective date of the change, then either party may immediately terminate the Agreement by written notice to the other party.

• Severability. If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of the Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable.

• Reimbursement for services rendered. If this Agreement is held to be invalid for any reason, and if Faith Family Medical Services is therefore required to refund all or any portion of the monthly fees paid by Patient, Patient agrees to pay Faith Family Medical Services an amount equal to the reasonable value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid.

• Amendment. No amendment of this Agreement shall be binding on a party unless it is made in writing and signed by all the parties. Notwithstanding the foregoing, the FNP may unilaterally amend this Agreement to the extent required by federal, state, or local law or regulation(“Applicable Law”) by sending you 30 days advance written notice of any such change. Any such changes are incorporated by reference into this Agreement without the need for signature by the parties and are effective as of the date established by Faith Family Medial Services, except that the Patient shall initial any such change at Faith Family Medical Services’ request. Moreover, if Applicable law requires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been expressly set forth in this Agreement.

• Assignment. This Agreement and any rights Patient may have under it may not be assigned or transferred by Patient.

• Relationship of Parties. Patient and the FNP intend and agree that the FNP, in performing her duties under this Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and/or the United States Department of Labor and the FNP shall have exclusive control of her work and the manner in which it is performed. 

• Legal Significance. Patient acknowledges that this Agreement is a legal document and creates certain rights and responsibilities. Patient also acknowledges having had a reasonable time to seek legal advice regarding the Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of the Agreement. 

• Miscellaneous. This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted. Captions in this Agreement are used for convenience only and shall not limit, broaden or qualify the text. 

• Entire Agreement. 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.

• Jurisdiction: This Agreement shall be governed and construed under the laws of the State of Tennessee, and All Disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for Faith Family Medical Services address in Arlington, Tennessee.

• Service. All written notices are deemed served if sent to the address of the party written above or appearing in Exhibit A first class U.S. mail. The parties have signed duplicate counterparts of this Agreement on the date first written above. 

Appendix 1

Services and Payment Terms

Medical Services. As used in this Agreement, the term Medical Services shall mean those medical services that the FNP herself is permitted to perform under the laws of the State of Tennessee and that are consistent with her training and experience as a Family Nurse Practitioner, as the case may be. Patient shall also be entitled to an annual in-depth “wellness examination and evaluation,” which shall be performed by the FNP and include the following:

• Health Risk Assessment
• Vision and Hearing Screening *
• Psychosocial Screening
• Custom Wellness Plan to Include Exercise and Dietary Plan, and Lifestyle Medicine 

*Some restrictions apply

The FNP may, from time to time, due to vacations, sick days, and other similar situations, not be available to provide the services referred to above in this paragraph 1. During such times, the Patient’s calls to the FNP, or the FNP’s office, will be directed to a healthcare provider who is “covering” for the FNP during her absence. Faith Family Medical Services will make every effort to arrange for coverage but cannot guarantee such coverage.

Controlled Substances: Faith Family Medical Services FNP is unable to prescribe controlled substances for chronic illness management, including but not limited to mood disorders and chronic pain. Controlled substances may be prescribed for acute issues (no longer than a 7 day period), and Faith Family Medical Services will provide referrals to appropriate specialists for further management. 

Cancellation/No Shows: We kindly request 24-hour notice when canceling appointments. Many appointments are scheduled with our providers for up to 1 hour. Last-minute changes are costly and inefficient. FFMS reserves the right to charge $50 for canceled appointments or no-show appointments with less than a 24-hour notice. Additionally, patients who miss 3 appointments without a provider’s excuse will be asked to leave the Practice. Please arrive on time for your appointment. Your time, as well as ours, is valuable. We do our best not to keep you waiting. If you are 15 minutes or later, you may be asked to reschedule your appointment. 

Non-Medical, Personalized Services. Faith Family Medical Services shall also provide Patient with the following non-medical services (“Non-Medical Services” ):

Direct Access. Patient shall have direct access to the FNP via text messaging and email. Patient shall also have direct telephone access to the FNP; the Patient shall be given a phone number where Patient may reach the FNP directly. During the FNP’s absence for vacations, continuing medical education, illness, emergencies, or days off, Faith Family Medical Services will recommend the services of an appropriately licensed healthcare provider for assistance in obtaining medical services for acute, in-office visits only. Non-urgent medical care, which can be managed via telemedicine, will still be conducted by Faith Family Medical Services FNP. Patient will be notified 30 days prior to any scheduled FNP absences to provide for any necessary scheduling changes or medical needs of the Patient. 

Email Access. Patient shall be given the FNP’s email address to which non-urgent communications can be addressed. Such communications shall be dealt with by the FNP or a staff member of the Practice in a timely manner. Patient understands and agrees that email and the internet should never be used to access medical care in the event of an emergency or any situation that the Patient could reasonably expect may develop into an emergency. Patient agrees that in such cases, when a Patient cannot speak to the FNP immediately in person or by telephone, that Patient shall call 911 or the nearest emergency medical assistance provider an follow the directions of emergency medical personnel.

No Wait or Minimal wait Appointments. Every effort shall be made to ensure that the Patient is seen by the FNP immediately upon arriving for a scheduled office visit or after only a minimal wait. If FNP foresees a minimal wait time, the Patient shall be contacted and advised of the projected wait time. 

Same Day/ Next Day Appointments. When the Patient calls or emails the FNP prior to noon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort shall be made to schedule an appointment with the FNP on the same day. If the Patient calls or emails the FNP afternoon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort shall be made to schedule the Patient’s appointment with the FNP on the following normal office day. In any event, however, Faith Family Medical Services shall make every reasonable effort to schedule an appointment for the Patient on the same day that the request is made. 

Home, Office or After Hours Visits. Patient may request that the FNP see the Patient in the Patient’s home or after hours in the office, and in situations where the FNP considers such a visit reasonably necessary and appropriate, she will make every reasonable effort to comply with the Patient’s request. Patient agrees to an extra fee of $100 for a home or after-hours visit.

Specialists.Your Faith Family Medical Services FNP shall coordinate with medical specialists to whom the Patient is referred to assist the Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialists’ fees or fees due to any medical professional other than the Faith Family Medical Services FNP. 

AUTOMATIC CREDIT / DEBIT CARD BILLING AUTHORIZATION

To enjoy the convenience of automated billing, complete the Credit/Debit Card information section below and sign the form. All requested information is required. Upon approval, you will have the option to make monthly payments or set up a monthly auto-deduction. Payments are made directly through your secure link accessed through your electronic statement sent to your email. Your statement will include monthly fees and incidental charges, which you will receive prior to any payments or deductions. Online enrollment form Terms of Service Agreement authorizes Faith Family Medical Services to do the following:

I authorize Faith Family Medical Services to automatically bill the card listed below as specified:

PAYMENT INFORMATION

Amount: As accrued Incidental Charges: As accrued

Frequency: As selected

Start billing on: Date of electronic enrollment submission

End billing on: Upon written request, 30 days prior to cancellation

CREDIT/ DEBIT CARD INFORMATION (Visa, Mastercard, American Express, Discover)

Credit Card Type: As Submitted

Credit Card Number: As Submitted

Expires: As Submitted

CVC: As Submitted

Cardholder’s Name: As Submitted

RELEASE OF RECORDS AUTHORIZATION

I request and *authorize Faith Family Medical Services to release my healthcare information to any entity or individual deemed appropriate. To include but not limited to the following:

human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific, urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereum, HIV (Human Immunodeficiency Virus), Aids (acquired immunodeficiency syndrome), and gonorrhea.

I authorize the release of my STD results and HIV/AIDS testing, whether negative or positive, to the person (s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone. 

I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.

*AUTHORIZATION IS VALID UNTIL REVOKED BY PATIENT