Patient Agreement
Inspire Family Medicine, PLLC
This is an Agreement between Inspire Family Medicine, PLLC located at: 45 Sterling Street, Suite 22, West Boylston, MA 01583 (“Inspire”), Jennifer LaBonte, MD (“Provider”) in her capacity as a physician, and the Patient(“Patient” or “You”).
Background
Inspire provides certain medical services to its patients through Provider at the address set forth above. In exchange for subscription fees paid by Patient, Inspire agrees to provide Patient with the Services described in this Agreement (in Appendix 1) on the terms and conditions set forth in this Agreement.
Definitions
1. Patient. A patient is defined as those persons for whom the Provider shall provide Services, and who are signatories to, or listed on the documents attached as Appendix 1, and incorporated by reference, to this Agreement.
2. 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 Inspire Family Medicine
and set forth in Appendix 1 and 2. The Patient will be provided with methods to contact the physician via phone, email and other methods of secure messaging via portal or messaging app. Physician will make every effort to address the needs of the patient in a timely manner, but cannot guarantee availability, and cannot guarantee that the patient will not need to seek treatment in the urgent care or emergency department setting.
3. Term. This Agreement shall commence on the date it is signed by the Patient and Physician below and will extend monthly thereafter. Notwithstanding the above, both Patient and Practice shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination. The Patient may terminate the agreement with twenty-four hours prior notice, but the Practice shall give thirty days prior written notice to the Patient and shall provide the Patient with a list of other Practices in the community in a manner consistent with local patient abandonment laws. Notification of termination by the Patient to the Practice must be in writing and have confirmation of receipt, such as certified mail or email with a response from the Practice. Notification of termination by the Practice to the Patient shall be delivered in the form of a certified letter. Unless previously terminated as set forth above, at the expiration of the initial term (and each succeeding monthly term), the Agreement will automatically renew for successive monthly terms upon the payment of the monthly fee by the end of the prior contract month. Examples of reasons the Practice may wish to terminate the agreement with the Patient may include but are not limited to:
- The Patient fails to pay applicable fees owed pursuant to Appendix 2 per this agreement;
- The Patient has performed an act that constitutes fraud;
- The Patient repeatedly fails to adhere to the recommended treatment plan, especially regarding the use of controlled substances;
- The Patient is abusive, or presents an emotional or physical danger to the staff or other patients of the Practice;
- Practice discontinues operation;
- Practice has a right to determine whom to accept as a patient, just as a patient has the right to choose his or her physician.
4. Fees. In exchange for the Services, Patient agrees to pay Inspire Family Medicine the monthly subscription amount as set forth in Appendix 2, attached. Applicable enrollment fees are payable upon execution of this agreement. This fee is payable upon execution of this Agreement and is in payment for the services provided to Patient during the initial term of this Agreement and for each month thereafter. If this Agreement is cancelled by the Patient at any time during the monthly billing cycle, Inspire Family Medicine shall not refund the Patient’s prorated share of the monthly subscription payment. If the Patient has paid upfront for an annual or 6 month membership and later wishes to terminate, the Practice will refund the prorated share of unused membership, calculated by the number of remaining whole months left in the membership cycle.
5. Non-Participation in Insurance. Patient acknowledges that neither Inspire Family Medicine, nor its Providers participate in any health insurance or HMO plans or panels and has opted out of Medicare. Neither Inspire Family Medicine nor its Providers make any representations whatsoever that any fees paid under this Agreement are covered by any 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 a separate agreement attached, labeled as “Medicare Private Contract” and incorporated by reference into this Agreement. This Agreement expressly acknowledges your understanding that the Provider has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for you by Inspire Family Medicine or its Providers. You, your successors, heirs, conservators, executors and administrators, agree not to bill Medicare or attempt Medicare reimbursement for any such services. Patient shall renew and sign the Medicare Private Contract every 2 years.
6. 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 directly or personally provided by Inspire Family Medicine or its Providers. Patient acknowledges that Inspire Family Medicine has advised the Patient to obtain or keep in full force such health insurance policy (ies) or plans that will cover Patient for general healthcare and hospitalization 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. This Agreement is for ongoing primary care, and the Patient may need to visit the emergency room or urgent care from time to time. Physician will make every effort to be available at all times via phone, email, and other methods such as “after hours” appointments when appropriate, but Physician cannot guarantee 24/7 availability. Furthermore, Patient understands that some insurance companies may restrict the Provider from making referrals or ordering labs/tests on the patient’s behalf. Patient understands that it is his/her responsibility to investigate and understand the rules and regulations of his/her insurance plan.
7. Communications. Upon commencement of your membership, the Practice will provide you with secure, encrypted methods of communication, including a free text-messaging app and a patient portal for your electronic health record. You acknowledge that all other forms of communication with the Provider such as e-mail, facsimile, video chat, instant messaging, social media messaging and cell phone are not guaranteed to be secure or confidential methods of communications. As such, you expressly waive the Provider’s obligation to guarantee confidentiality with respect to correspondence using such means of communication that you may request. You acknowledge that all such communications may become a part of your medical records. By
providing Patient’s email address on this Agreement, Patient authorizes Inspire Family Medicine and its Provider to communicate with the Patient by email regarding patient’s “protected health information” (PHI) (as that term is defined in the Health insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulations). By inserting Patient’s email address in this Agreement Patient acknowledges,consents and agrees 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 Provider will make all reasonable efforts to keep e-mail communications confidential and secure, neither Inspire Family Medicine nor the Provider can assure or guarantee the absolute confidentiality of email communications;
- In the discretion of the Provider email communications may be made a part of Patient’s permanent medical record;
- If the patient initiates a conversation in which the Patient discloses “Protected Health Information (PHI)” on one or more of these communication platforms then the Patient has authorized the Practice to communicate with the Patient regarding PHI in the same format and,
- Patient understands and agrees that 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 Patient could reasonably expect to develop into an emergency, the Patient should call 911 or go to the nearest emergency room and follow the directions of emergency personnel.
If Patient does not receive a response to an e-mail message within one business day, Patient agrees to use another means of communication to contact the Provider. Neither Inspire Family Medicine, nor the Provider will be liable to Patient for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to 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, or faulty telephone or cable data transmission;
- Any interception of email communications by a third party; or
- Your failure to comply with theguidelines regarding use of e-mail communications set forth in this paragraph.
8. Change of Law. If there is a change of any law, regulation or rule, federal, state or local, which affects this Agreement 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 thirty days after the date of the effective date of change, then either party may immediately terminate the Agreement by written notice to the other party.
9. 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.
10. Reimbursement for services rendered. If this Agreement is held to be invalid for any reason, and if Inspire Family Medicine, is therefore required to refund all or any portion of the monthly fees paid by the Patient, Patient agrees to pay Inspire Family Medicine, an amount equal to the reasonable value of the Services actually rendered to the Patient during the period of time for which the refunded fees were paid.
11. 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 Provider 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 Inspire Family Medicine. 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.
12. Assignment. This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient.
13. 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.
14. Miscellaneous. This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafting. Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text.
15. 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.
16. Jurisdiction. This Agreement shall be governed and construed under the laws of the Commonwealth of Massachusetts and all disputes arising out of this Agreement shall be settled in the courts of proper venue and jurisdiction in Worcester County, Massachusetts.
17. Service. All written notices are deemed served if sent to the address of the party written below or appearing in Exhibit A by certified mail.
