Patient Agreement for Physician Services

Updated Terms of Service Dated 12.01.15

1. Subscription Medical Practice Explained.

Griffin Concierge Medical (“Practice”) is a voluntary subscription medical practice solely owned and operated by Griffin Concierge Medical. A subscription medical practice is a type of medical practice that limits the number of patients the practice treats.  This limitation of the number of patients allows Practice physicians to be more personally available and offer more services to patients.  The Practice provides its patients with the full range of medical services provided in a traditional family medical practice.

2. Services and Benefits.

The Practice agrees to provide the services and benefits described in Schedule 2.1 of this Agreement (“Services”) to the Patient in exchange for a fee paid by the Patient as described in Section 3. The Practice reserves the right to update this schedule of Services from time to time, and if it does, it will notify the Patient of any changes within thirty (30) days after a change is made.

When the Patient is Medicare eligible, if applicable, the Patient acknowledges that all electronic communications offered as Services do not include those provided as Medicare benefits, including communications related to office visit scheduling or following-up on an office visit covered by Medicare; communications based on emergent medical needs; communications related to chronic care management services covered by Medicare; and/or post-hospitalization telephone follow-up communications.  Any telemedicine services offered as Services are in addition to “telehealth” services or remote “non face-to-face” services covered by Medicare.

The Patient acknowledges that in no event shall the Services be deemed to include “access” to the Practice, abbreviated scheduling times or extended office visits, “care coordination” with other physicians covered or bundled with covered services, emergency medical services, “24/7” communication access (other than those specified above in excess of mandated electronic records access), or the provision of chronic care management services covered by Medicare.  These practice benefits may occur incidentally and solely due to the Practice’s reduced patient panel size, electronic communication portal amenities, and medical office efficiencies.

3. Voluntary Subscription Fee ("Practice Fee").

The Patient agrees to pay the Practice a voluntary subscription fee each year for the Services provided pursuant to this Agreement. The Patient agrees to a minimum three (3) month financial commitment to the Practice, during which time the subscription cannot be cancelled. The Practice reserves the right to periodically adjust the Fee, but the Fee will not be adjusted more frequently than once per year based on the original date of this Agreement.

4. Payment Options

The Patient agrees to pay the Practice Fee each (1) year period, pursuant to this Agreement. The Patient authorizes the Practice to automatically charge the Patient’s pre-arranged method of payment for all installment charges related to this Agreement. The Practice requires automatic, electronic recurring payments either via debit/credit card or bank ACH. The Practice Fee will be automatically processed on the same date monthly, quarterly, semi-annually or annually. The Patient must maintain a valid method of payment at all times. Practice Fees are managed via our Hint Health membership payment system. The Patient may receive email correspondence from Hint Health when a payment method needs attention or when payment is due.

5. Additional Patient Services.

If the Practice provides testing or services other than the Services listed in Schedule 2.1, the Patient and the Physician may mutually agree upon additional charges. The Practice will automatically bill the Patient’s pre-arranged method of payment for any charges related to his/her account including, but not limited to, laboratory, pharmaceutical, and product fees.

6. Term.

The initial term of this Agreement shall be for one (1) year after the Patient’s payment of the Practice Fee or the first examination described in Schedule 2.1; whichever occurs first. The term shall automatically renew for a subsequent one (1) year term provided that the Patient pays the Practice Fee each term and the Agreement is not otherwise terminated as described in Section 7. If the Patient does not pay the Practice Fee upon expiration of the previous one (1) year term, this Agreement does not automatically renew.

7. Delinquent Accounts.

Accounts sixty (60) days past due will be considered inactive and this Agreement will expire and become null and void for the purpose of the provision of Services to the Patient. The Patient may be reenrolled at the discretion of the Practice, if Practice capacity has not been reached. A re-enrollment fee equal to one month of the Practice Fee will be assessed. All past due invoices, late fees and re-enrollment fees must be paid prior to re-enrollment.

8. Termination of Agreement.

The Patient may terminate this Agreement at any time and for any reason upon thirty (30) days advanced written notice to the Practice. The Patient may be refunded a prorated amount after thirty (30) days advanced written notice. Refunds will include the balance of any monies paid in advance, less a prorated amount based upon the length of the remaining subscription period and the value of the Services received, and the non-refundable three (3) month portion of the Practice Fee. The Practice may also terminate the Patient’s subscription to the Practice immediately upon notice, unless the Practice, within its discretion, decides that it is in the Patient’s best interest to have a longer notice period prior to termination. If the Patient terminates their authorization for automatic billing without advance written notification to the Practice, the Patient’s subscription to the Practice may be terminated. Upon termination of this Agreement, at the Patient’s request, the Practice will recommend another local family physician for continuation of care and/or medication management, and will provide medical records. At that time, the Patient agrees to no longer utilize the personal cell phone number and email address of Practice physicians. Any inquiries made after the termination of this Agreement must be made via the Practice telephone number: (813) 350-9090.

9. The Practice Does Not Bill Private Insurance.

The Patient acknowledges that the Practice will not file or accept a private insurance claim as payment for patient care, and the Practice makes no representations or promises regarding whether their services are covered by private insurance or reimbursable through a health care spending account or other health care product. However, at the Patient’s request, the Practice may provide the Patient with or submit, as a courtesy and on behalf of the Patient, to the Patient’s private health insurance plan (other than Medicare) a coded insurance claim form or a billing document (i.e. a “superbill”) outlining medical services provided to the Patient.

10. Medicare.

The Patient acknowledges that Practice physicians are  participating Medicare providers. Due to federal regulations, claims will be submitted to Medicare for all Medicare-covered services provided to the Patient. Medicare-eligible patients are responsible for any co-pays and/or deductibles. The Patient acknowledges that the Services constitute non-covered Medicare services beyond what Medicare covers or reimburses the Practice for providing to the Patient. The Patient accepts full responsibility for the payment of the Practice Fee. The Patient agrees not to submit a claim to Medicare for payment of the Practice Fee nor request that the Practice submit such a claim. The Patient acknowledges and understands that Medicare will not pay for the Services referenced in Schedule 2.1.

11. Consent of Treatment.

The Patient authorizes and consents to Practice treatment and procedures, and certifies that no guarantee or assurance has been made as to the results obtained.

12. Complications

The Patient understands that it is his/her responsibility to contact the Practice to report any change in condition.

13. Vacations and Illness for Practice Physicians.

The Patient acknowledges that there may be times that the Patient cannot contact a Practice physician due to vacations, illness, or technical defects.  The Patient acknowledges that, should a Practice physician become unavailable, the Practice shall make every effort to give sufficient advance notice to the Patient so that Services can be scheduled on another date.  In cases of emergency, contact information for a covering provider will be offered, although any fees associated with services provided by the covering provider will not be paid by the Practice or be considered fees for Services included in the Practice Fee.

14. Compliance with Law and AMA Policy.

In establishing this voluntary subscription medical practice, the Practice intends to do so in compliance with any applicable laws and in compliance with the American Medical Association’s Policy on Concierge Medical Practices.  In the event the law changes and renders a provision of this Agreement invalid or unenforceable, the Practice will work with the Patient to amend the Agreement to comply with applicable law if possible.  If any provision of this Agreement is deemed to be or declared invalid or unenforceable, the remainder of the Agreement will be valid and enforceable.

15. The Practice is Not an Insurer.

The Practice is not an insurance company and is not promising unlimited care for the Practice Fee. The Practice presumes that the Patient is either eligible for Medicare or has health insurance that provides health care coverage for services not covered by the Practice Fee.

16. Notices.

All notices, requests, demands, or other communications provided for in this Agreement shall be in writing and shall be deemed to have been given at the time when personally delivered, or mailed in a registered or certified prepaid envelope, return receipt requested, or sent by overnight courier which regularly provides receipts and addressed to  Griffin Concierge Medical, 1315 South Howard Avenue, Suite 102, Tampa, FL  33606, Attention:  Radley L. Griffin, M.D.

17. General

The Patient’s subscription to the Practice shall be completed with the execution of this Agreement by each Patient and Responsible Party, and receipt of the Practice Fee.  This Agreement shall be governed by the laws of the State of Florida. without application of choice-of-law principles. This Agreement replaces and supersedes all prior agreements between the Patient and the Practice.  This Agreement may not be modified absent a writing signed by the Patient and an authorized representative of the Practice. If any term of this Agreement is deemed invalid or in violation of any superseding law or policy, the remaining terms of this Agreement shall remain in full force and effect. A photocopy or digital copy of the signed original of this Agreement may be used by the Patient or the Practice for all present and future purposes.

SCHEDULE 2.1

GRIFFIN CONCIERGE MEDICAL

1.) In addition to the one-time “Welcome To Medicare” physical and Annual Wellness Visits (“AWV”) covered by Medicare or the Patient’s private health insurance plan (if applicable), the Patient will be offered a routine annual wellness exam and physical that will include a comprehensive screening and assessment appropriate for the Patient’s age and risk factors.

2.) Office wellness visits and consultations relating to prevention and self-management of illness education and training.

3.) House calls without charge for travel costs associated with any such visits for patients residing in assisted-living facilities, including after-hours visits, regardless of medical necessity.

4.) After-hours direct telephone, electronic communication and telemedicine videoconferencing with the Patient related to health, diet, nutrition, and fitness education.

5.)  Personal assistance with data management in the Personal Health Records (“PHR”) platform (collectively “PHR Support”) which includes:
a.)  Results of most recent non-covered routine physical or additional non-covered wellness visit;
b.)  Dates and results of tests and screenings; and
c.)  Wellness and prevention education electronic communications.

6.)  Periodic Practice Newsletter.

7.)  International travel medical support via electronic communication.

8.)  Periodic, non-diagnostic, audiometry screening.

9.) Compliant prescription drug disposal.

10.)  OSHA-compliant biomedical waste disposal (ie., for personal use).