Inspire Health Direct Primary Care

Private Practice-Patient Agreement

 

Effective Date:_______________________________

 

Patient (s):__________________________________________________________       

                 __________________________________________________________

                ___________________________________________________________ 

                ___________________________________________________________

Street Address:  

 

Phone Numbers Home:   

Phone Numbers Mobile:

Mailing address (if different from above):

Please check here if responsible party information is same as patient  (  Responsible Party and Patient(s) are collectively referred to as “Patient” in this Agreement.)

Responsible Party:

Street Address:

Phone Numbers Home: 

Phone Numbers Mobile:

Mailing Address (if different from above)

 

Inspire Health Direct Primary Care, LLC (“Private Practice”) offers participating patients the opportunity to receive certain amenities and features, as described below.  This Private Practice-Patient Agreement (“Agreement”) describes the terms and conditions under which Private Practice shall deliver such amenities to the undersigned patient (“Patient”) receiving Private Practice Amenities.  (Private Practice and Patient are each individually referred to as “Party”, or collectively as “Parties”).

 

Private Practice offeres personalized primary health and wellness care to assist Patient achieve individual wellness goals.  Private Practice does not accept any form of health insurance and/or Medicare (“Plan”).  In exchange for the fees described below, Private Practice provides Patients with the following services (“Amenities”):

 

  • Health Exams

  • Office visits

  • Well-Child Checks

  • Convenient appointment scheduling

  • Private Practice connection via text or telephone contact

  • Physicals as medically directed or necessary

  • Commercial Drivers License physicals

  • EKG

  • Pulmonary function testing

  • Minor wound care

  • Minor skin excisions and biopsies (pathology lab fee is additional)

  • Essential/basic primary care services

 

SERVICES AVAILABLE FOR ADDITIONAL FEES:

Modest selection of generic medications available at 15% over cost

Labs are available at cost

Expansive primary care beyond essential or basic primary care (more than ten (10) office visits per month may trigger additional fees or expenses, in addition to, Private Practice’s usual and customary fees for more significant levels of office visits.   

SERVICES NOT PART OF THE AMENITIES:

Hospitalizations or hospital care, X-rays, emergency room visits, prenatal or obstetrical care, surgery, specialist office visits, cosmetic services, pediatric vaccinations are not part of the Amenities.  Vaccinations may require additional format and added fees.  Amenities are covered by the Private Practice’s Fee, discussed below.  Patient must never submit a request for reimbursement for Private Practice Fee to Medicare.  Dr. Frantz has voluntarily opted out of Medicare.  If Patient is Medicare-eligible, patient is entitled to receive medical services covered by Medicare from  a Medicare participating physician, but is voluntarily electing to contract with Private Practice for the Amenities and essential primary care. 

PRIVATE PRACTICE IS NOT AN INSURANCE PLAN:

Private Practice is not an insurance company or plan, and does not promise unlimited care in exchange for private Practice Fee as defined below.  Private Practice presumes that Patient has health insurance that provides health care coverage for services not covered by the Private Practice Fee.  Participation in Private Practice does not meet any individual health benefit plan mandate that may be required by federal law and the patient is not entitled to health insurance protections for consumers under Title 10.  (CO HB 17-1115).  

PRIVATE PRACTICE FEE FOR AMENITIES:

  • Private Practice fees for Amenities (“Private Practice Fee”) are as follows:

  • Patients aged 0 to 18 years:  $35 per person per month

  • Patients ages 19+:  $85 per person per month

  • Family up to 2 adults and 2 children:  $200 per family per month

Private Practice Fee reserves the right to adjust the Private Practice Fee annually with advanced notice from Private Practice to Patient. 

Participation in the Private Practice is personal to each individual accepted into the Private Practice, and may not be assigned. 

PRIVATE PRACTICE TERMINATION:

Either Party may terminate this Agreement at any time for any reason with thirty (30) days’ prior written notice.  If Patient provides notice to terminate this Agreement, Private Practice will charge Patient’s card for the final month and no refunds are given. 

Private Practice may also terminate this Agreement at any time with less than thirty (30) days’ notice should Patient: 1) fail to timely pay the Private Practice Fee or statements for health care services provided;  or 2)  violate Private Practice’s policies or instructions.  If Patient subscribes to Private Practice’s Amenities after termination and Private Practice accepts Patient, Patient shall pay a $300 reinstatement fee.  Acceptance back into the Private Practice is at the discretion of the Private Practice.  

Participation in Private Practice is limited to a select number of participants in order to preserve and retain the personal private character of health care services provided, and private Practice retains sole rights regarding Patient participation and services, and Private Practice reserve the right to decline to renew any annual enrollment. 

PRIVATE PRACTICE FEE PAYMENT OPTIONS:

Private Practice requires that all participating Patients keep a credit, debit card, or direct debit information on file. In lieu of using a credit or debit card, the patient may elect to set up recurring ACH transactions where the monthly fee and any additional expenses are debited from the patients bank account directly. This is the preferred method of payment as the costs from the financial institution are the lowest.  Private Practice will automatically charge Patients private Practice Fee amount each month, or annually in advance, if Patient prefers. 

Payment of the Private Practice Fee indicated above shall be charged monthly to the credit or debit card, or bank account, on the day chosen by the Patient at the time of enrollment.  

Patient authorizes the Private Practice to charge any Private Practice Fee to Patient’s credit or debit card or bank account, until such authorization is revoked by Patient or this Agreement is terminated.  Absent contrary instructions, Patient authorizes private Practice to use Patient’s credit/debit card, or bank account for the payment of any additional fees for professional services.  

As a courtesy, Private Practice may, upon Patient’s request, provide Patient with a filling document that outlines the medical services Private Practice provided so that Patient may submit it to Patient’s Plan for reimbursement (other than Medicare).  There is no guaranty that Private Practice’s invoices will be reimbursed in whole or in part by Plan. 

Patient will never submit any Private Practice Fee or any other fees or statements from Private Practice to Medicare for payment or reimbursement.  

MEDICARE OPT-OUT BY DR. FRANTZ FOR MEDICARE-ELIGIBLE PATIENTS:

Dr. Frantz has voluntarily opted out of the Medicare program effective on January 1, 2016.  Dr Frantz is not “excluded” from participating in Medicare under 1128, 1156, or 1892 of the Social Security Act.  Dr. Frantz agrees to provide the Amenities described in this Agreement to Patient.  Patient, or Patient’s legal representative, agrees, understands, and expressly acknowledges the following as a Medicare-eligible patient:

Patient, or Patient’s legal representative, acknowledges that patient is not currently in an emergency or urgent health care situation and is not seeking urgent or emergency care at this time.  Initials________

Patient, or Patient's legal representative, accepts full responsibility or payment of Private practice’s charges for all services furnished by Private Practice.  Initials_____

Patient, or Patient's legal representative, agrees not to submit a claim to Medicare or to ask the Private Practice to submit a claim to Medicare for any of Private Practice’s services.  Initials_____

Patient, or Patient’s legal representative, understands that Medicare payment will not be made for any items or services furnished by Private Practice that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.  Initials_____

Patient, or Patient’s legal representative, enters into this Agreement with the knowledge that Patient has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and Patient is not compelled to enter into private contracts the apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out.  Initials______

Patient or Patient’s legal representative, understands that Medigap plans do not, and the other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.  Initials_____

Patient, or Patient’s legal representative, acknowledges that a copy of this agreement has been made available to Patient.  Initials______

ADDITIONAL PATIENT ENROLLMENT TERMS:

Patient’s participation with Private Practice is complete once Patient signs this Agreement and Private Practice receives Patient’s initial Private Practice Fee payment.  This Agreement is governed by the laws of the State of Colorado, without application of choice-of-law principles. 

This Agreement replaces and supersedes all prior agreements between the Parties.  This Agreement may not be modified absent a writing signed by Patient and Private Practice’s authorized representative.  If any term of this Agreement is deemed invalid or in violation of any law or policy, the remaining terms of this Agreement shall remain in full force and effect. 

Either Party may use an electronic or digital copy of the signed original Agreement for present and future purposes.  Each participating Patient over the age of 21 is required to sign below. 

 

PRIVATE PRACTICE                                                                                          PATIENT/RESPONSIBLE PARTY

Inspire Health Direct Primary Care, LLC

a Colorado limited liability company

 

Signature_________________________                                                    Signature:_______________________

By:   Paula J Frantz, MD                                                                                   Printed Name:____________________

                                                                                                                          Relationship to Patient:_____________

                                                                                                                          Signature: _______________________

                                                                                                                         Printed Name:____________________

                                                                                                                         Relationship to Patient: _____________

 

Dr. Frantz is honored to be your physician, and looks forward to being your health care adviser, advocate, and coach.  THANK YOU!