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Service Agreement and Hippa Disclosure


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WASHINGTON DIRECT PRIMARY CARE AGREEMENT BETWEEN PROVIDER AND PATIENT

The DIRECT PRIMARY CARE AGREEMENT BETWEEN PROVIDER AND PATIENT (the “Washington Direct Primary Care Agreement”), is by and between the direct primary care provider (“Provider”) selected upon enrollment through Patient Direct Care (“PDC”) and the patient (“Patient”) as named in the enrollment forms.

1. Purpose of Direct Primary Care Agreement.
The purpose of the Direct Primary Care Agreement is to explain the scope of services provided by Provider to the Patient in exchange for Patient directly paying a set monthly fee as well as describe the terms and conditions of this Direct Primary Care Agreement. Direct Primary Care is not insurance.
Membership includes a limited scope of primary care services specified in section 12 of this agreement.
2. Agency.
Provider has appointed PDC to act as its agent in enrolling Patient as a direct primary care patient of Provider and Provider represents to Patient that PDC has authority to bind Provider to the terms and conditions of this Direct Primary Care Agreement.
3. Services Provided.
Direct Primary Care is not insurance. DPC provides only the limited scope of Primary Care Services specified in section 12 of this agreement. The patient is responsible for payment of all services not specified in the Direct Primary Care Agreement. Patient may cancel membership at any time.
Upon request, PDC will provide Patient a printed copy of the Services.
__________ Patient Initial *Patient acknowledges the clinic will NOT submit an invoice to the patient’s insurance for any services provided under their Direct Primary Care Agreement.

4. Excluded Services.
For excluded services, the Provider will provide Patient with advance notice of any additional charge prior to administration or delivery of an excluded service or alternatively, recommend that you obtain from your insurer or health plan provider a referral for further treatment. The Patient must pay for all services not covered under Patient’s membership.
5. Prescription Drugs.
Prescriptions may be offered at the patient’s clinic for a discounted cash price.
6. Monthly Fee.
PDC will bill the Patient monthly on the anniversary date of Patient’s enrollment according to the option Patient selected during enrollment. A schedule of the monthly fees by category is listed below.

www.patientdirectcare.com 360.999.5138 info@patientdirectcare.com
Patient will receive their bill and unless Patient has made other prior arrangements with PDC, payment will be automatically deducted from Patient’s bank account as set up by Patient during enrollment. Others, such as Patient’s employer, may pay the monthly fee on Patient’s behalf. If someone other than Patient will pay Patient’s monthly fee, please provide this information to PDC.
a. Individual $75/month
b. Individual + Dependent $140/month
c. Family up to 4 $200/month
d. Each additional family member after 4 $40/month
7. Fee Increases.
The Monthly Fee schedule listed in Section 6 is valid for twelve (12) months. If Patient’s monthly fee is scheduled to increase after the 12th month of services provided to Patient under this Direct Primary Care Agreement, PDC on behalf of the Provider will provide Patient at least sixty (60) days advance written notice. We will not raise Patient’s monthly fees more than once annually.
8. Late Payments.
Payment will be considered late and Patient’s membership will be suspended if Patient’s payment is not received within thirty (30) days of invoicing. If Patient is unable to pay the monthly fee for any reason, it is Patient’s responsibility to contact PDC in order to make prior arrangements to make a late payment without termination. If Patient does not contact PDC before Patient’s payment is late, we reserve the right to terminate this Direct Primary Care Agreement. If Patient does not pay Patient’s monthly fee within sixty (60) of invoicing, we may terminate this Direct Primary Care Agreement in accordance with the terms below.
9. Termination/Cancellation.
Patient may terminate this Direct Primary Care Agreement at any time and for any reason. A cancellation form is provided to Patient at the clinic or through the Portal. PDC will return a prorated portion of the monthly fee to Patient if membership is canceled within the month paid. PDC will process a refund of Patient’s membership dues to the same account the patient used during enrollment within 1 – 3 business days if cancelled within the first week of new membership month and patient has not used any membership services for the new billing period. Availability of refund may be delayed by third parties. Check with your bank for further details. During the twelve (12) month period after Patient signs this Direct Primary
Care Agreement, we may only terminate this Direct Primary Care Agreement for one of the following reasons:

a. Patient fails to pay the direct fee under the terms required by this Direct
Agreement;
b. Patient performs an act that constitutes fraud;
c. Patient repeatedly fails to comply with a recommended treatment plan;
d. Patient is abusive and/or presents an emotional or physical danger to the staff or other
patients; or
e. The Provider discontinues operation as a direct practice.
f. Provider feels you may not be a good fit for their clinic.

In the event that we elect to terminate this Direct Primary Care Agreement under this section, we will provide Patient with notice and opportunity to obtain care from another Provider. If Patient cancels membership twice (2) within one year, the Provider reserves the right to deny acceptance of Patient into the Providers direct primary care membership at their clinic.

10. Complaints.
In the event that Patient has any complaint about the services provided under this Direct Primary Care Agreement, Patient shall contact the following person for further assistance:
Patient Direct Care
209 East Main Street
Suite 121
Battle Ground, WA 98604
Attention David Tracy
(360) 999-5138
info@patientdirectcare.com

11. No Discrimination.
The Provider does not decline to accept new direct patients or discontinue care to existing patients solely because of the patient’s health status. Further, the Provider does not decline to accept any person solely on account of race, religion, national origin, the presence of any sensory, mental, or physical disability, education, economic status, or sexual orientation.
12. Direct Primary Care Services.
* Each clinic utilizing PDC is independently owned and operated. You may or may not have all of the same offerings available at each clinic. PDC may have discounted prices for services not covered by your PDC membership. Check with your provider or contact PDC directly.

Covered Services

Services
Primary Care Visits Included
Urgent Care Visits Included
Preventive Care Included
Annual Wellness Exams Included
Well Child Exams Included
Sports Physicals Included
Telemedicine (Email, Phone, Remote Portal Consults) Included

Procedures
EKG Included
PPD (TB Test) Included
Injection Fees (medication costs may not be covered) Included
Immunizations (medication costs may not be covered) Included
Skin Lesion Excision and Biopsy (pathology fees not included) Included
Skin Lesion Removal/Destruction (skin tag, wart, other) Included
Uncomplicated Wound Suture Included
Flu Shot Included
Ear Irrigation Included
Nebulizer Treatments Included
Liquid Nitrogen Procedures Included
Smoking and Tobacco Cessation Counselling Included
Hearing Test Included

Labs
Urinalysis Included
Blood Glucose Included
Urine Pregnancy Test Included
Lipid Profile Included
HgbA1c Included
Rapid Strep Test Included
Alcohol and Substance Abuse Screening Included
Additional Services
Discount Prescription Card Included
Prescription Savings Portal Included
Discount Mail Order Prescription Program Included
Specialty Care Triage/Support Included

{Authorization and Signature Page Follows}
I, the Patient, authorize signature by electronic means to this Direct Primary Care Agreement and any other documents or instruments that may be provided to me during enrollment or thereafter. By affixing my electronic signature to this Direct Primary Care Agreement during enrollment, I acknowledge and agree that:
(a)
I have read this Direct Primary Care Agreement; and, (b) prior to enrollment I had an opportunity to discuss any questions I may have had about the terms contained within this Direct Primary Care Agreement with the Provider. Further, I have the right to have this Direct Primary Care Agreement provided or made available on paper or in non-electronic form at no additional fee to me. I may update my electronic contact information or withdraw consent at any time of the use of my electronic signature by contacting PDC at the address, phone
number or email in Section 10 above.

Patient Signature

Signature: _________________________________________________

Date: ______________________________________________________

HIPAA
Patient Consent Form
This notice provides information about our Privacy Practices and how we may use and disclose protected health information about you. Prior to signing this consent you have the right to review our Privacy Practices. Privacy Practices terms may change at any time. If the terms of Privacy Policy has changed you may obtain a copy by contacting our office at:
Patient Direct Care
209 East Main Street
Suite 121
Battle Ground, WA 98604

You may request that we restrict how your protected health information about you is used or
disclosed for any treatment, payment or health care operations. Although we are not required to abide by this restriction, if we do, we may honor that agreement.

By signing this form, we are getting your consent to use and disclosure your protected health information. This information may include information for treatment, payment and healthcare operations.

You may revoke this consent in writing, signed by you. Any revocation shall not
effect any disclosures we have already made with your prior consent. Our company provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The patient understands that:
• Information about my protected health information may be disclosed or used for treatment, health care operations or payment.
• The patient has had an opportunity to read and review our Notice of Privacy Practices.
• Information about the patient may be restricted but that the practice does not have to agree to the restriction
• Patient may revoke this consent at any time in writing for all future disclosures to cease

Signed By: ________________________________________________________

Printed Name: _____________________________________________________

Relationship to patient
(if other than patient) _____________________________________________________

www.patientdirectcare.com 360.999.5138 info@patientdirectcare.com

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We are proud to join the Medical Professionals in Battleground, and offer local residents and businesses an opportunity to receive first class Primary Care without insurance. At our clinic there are no co-pays, or forms to submit to an insurance company. No rushing to see 30 patients per day. Just Old Fashioned Medicine available to you 24/7.

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Using the best Medical Technology and Skills available.
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We don’t watch the clock.
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Call us anytime that You need us.
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