PATIENT AGREEMENT
This is an Agreement between Members Health Co, Dr. Kyle Moore (Provider)
And
___________________________________________
(Patient or Patient’s Representative for Patient, or You or Your)
BACKGROUND:
Dr. Kyle Moore, a Board-Certified Emergency Medicine Physician in Tennessee, provides primary care, preventive medicine, and urgent care services through Members Health Co. He would be honored to be your care provider. With that in mind he agrees to provide you the Services described in this agreement on the terms and conditions below. Additional information regarding the Provider, the direct primary care model, and the care they provide can be found on the Practice’s website at www.membershealthco.com.
AGREEMENT:
What We’ll Do. Members Health Co provides you with primary care services on an ongoing basis for acute, chronic, and wellness issues. We will work with you to develop a care plan that meets your needs, based on discussion and interaction with the Provider. We will meet with you in person, or via tele medicine (where appropriate). We will offer multiple means of communication, including in-person, via patient portal, via phone, and via secure e-mail. We will strive to understand your needs and concerns and work with you to make you healthier.
Membership. Patient hereby agrees to enroll as a Member with the Practice direct beginning on the Effective Date set forth below. By being a Member, Patient shall be eligible to receive basic medical services described in Appendix 1 – Services Provided, attached hereto and made a part hereof, and shall be subject to the conditions and limitations described therein. Membership in the Practice’s Membership Program includes only the Services Provided specifically described in Appendix 1. The Practice may add or discontinue Covered Services at any time, as it may choose in its sole discretion. The Practice shall provide at least sixty (60) days’ advance written notice upon any change to the Services Provided listed in Appendix 1.
What We Charge. Patient agrees to pay a monthly fee (“Membership Fee”) in accordance with the schedule attached hereto in Appendix 2, and made a part hereof (“Membership Fee Schedule”). Your payment is used at the beginning of each month to pay for the services we will provide in that month. The fee will be auto deducted on the last day of the month prior to the month that is being paid for. Membership Fees shall be pro-rated for the first month only. Any fees or charges that are not included in the Membership Fee (i.e. fees for non-covered services) shall be due at the time of service. Though we aim for pricing stability, we must reserve the right to increase our fees. Of course, we will provide you with at least 60 days’ written notice prior to implementing any change.
Our Limits. We only provide the primary care services specified in Appendix 1 – Services Provided. The Provider will make every effort to address Your needs in a timely manner, but cannot guarantee immediate availability, and cannot guarantee that You won’t need to seek treatment at a specialist clinic, an urgent care, in the emergency department, or hospital setting. If so, those costs will not be included in Your membership. The Provider cannot guarantee after-hours availability.
De-Identified Information in Advertising. "De-Identified Information" refers to data that removes any personally identifiable information ensuring that the individual to whom the data pertains can no longer be identified. You consent to Members Health Co using your de-identified information for advertising purposes. You also have the right to voluntarily withdraw consent at any time at which point no further information will be used or promoted.
We Do Not Take Insurance. The Provider has made a very conscious decision NOT TO ACCEPT OR PARTICIPATE IN ANY INSURANCE PRODUCTS OR PROGRAMS. This means that Your Provider does not submit any claims to insurance and does not receive any reimbursements from insurance. Tennessee Code 63-1-504 imposes a prohibition on the patient and primary care provider from submitting a bill to an insurer for the services provided under the agreement. You should therefore anticipate that the fees You pay for Services will not be covered by any insurance You may have. We are not accepting Medicare or Medicaid patient at this time, but we hope to in the near future – interested Medicare/Medicaid patients are invited to join a waitlist to stay updated.
And We Are Not Insurance. It’s important You understand that this agreement and the Services arrangement it describes are NOT an insurance plan, or a substitute for health insurance or other health plan coverage. This agreement does not provide health insurance coverage, including the minimal essential coverage required by applicable federal law. We do NOT cover hospital, surgery center, or similar services, or any other medical needs not personally provided by the Provider and described below. We recommend that You obtain and keep a health insurance policy(ies) or plan(s) that will cover facility fees (hospitals, specialists, and urgent care offices, for example) and general health care costs not included in the Services. It may be possible to use employer benefits and tax-advantaged health benefits opportunities to pay membership fees – please follow up with Your specific employer to see if this is possible. It is possible to use an HRA, HSA, or FSA account to pay Your membership fees, but You should follow up with Your employer or tax advisor.
Cancellation and Refund Policy. You can cancel Your membership at any time after the first 180 days and the membership will be terminated at the end of the calendar month. There is no cancellation fee or charge. Your eligibility to Services begins the day You make Your first membership payment, unless we otherwise agree in writing, and continues monthly thereafter so long as You continue making timely payments when due. Either You or we may terminate the agreement any time. You may terminate with a 30-day prior notice. Upon termination, pre-paid future membership fees will be refunded within 30 days of our receipt of your notice of termination. Since your payment is used for the entire month on the first day of the month, You will be able to continue to use your membership until the end of the month in which you terminate. If we terminate, unless you are abusive or pose an emotional or physical danger to our staff, we’ll advise You in writing 30 days in advance. Patients who are abusive or pose a danger to staff may be terminated immediately. Reasons the Practice may terminate this agreement include but are not limited to:
• You fail to pay applicable fees owed pursuant to the Appendix 2 – Membership Fees;
• You act fraudulently or engage in certain criminal acts;
• You repeatedly fail to adhere to the recommended treatment plan, especially
regarding the use of controlled substances; or
• We discontinue the Program; and the Practice closes its doors.
Reinstatement. In the event Patient terminates this Membership Agreement after the Effective Date hereof, Patient shall be ineligible for membership for a period of three (3) months following the effective date of termination, unless Patient pays a fee in the amount of five hundred dollars ($500.00) (“Reinstatement Fee”). If You are a Founding Member and You cancel Your Membership at any time, You will forfeit this discount if You ever re-join the Practice in the future.
Indemnification. Patient agrees to indemnify and to hold the Practice and its members, officers, directors, agents, and employees harmless from
and against all demands, claims, actions or causes of action, assessments, losses, damages, liabilities, costs and expenses, including interest, penalties, attorney fees, etc. which are imposed upon or incurred by the Practice as a result of the Patient’s breach of any of Patient’s obligations under this Agreement.
Entire Agreement. This Membership Agreement constitutes the entire understanding between the parties hereto relating to the matters herein contained and shall not be modified or amended except in a writing signed by both parties hereto.
Waiver. The waiver of either the Practice or Patient of a breach of any provisions of this Membership Agreement must be in writing and signed by the waiving party to be effective and shall not operate or be construed as a waiver of any subsequent breach by either the Practice or Patient.
Appointments. We prefer that You schedule visits more than 24 hours in advance when possible. Note, we are available for walk-in urgent care services.
Patient Responsibilities. As a patient of the practice, you agree to the following:
• To provide the Practice your contact information and to notify the Practice of any changes.
• To provide the Practice with payment information.
• To pay the fees identified in Appendix 2 – Membership Fees on time as established with the Practice.
• To work with the Provider and share information about your health, activities, and needs.
• Where possible, to schedule appointments with the Provider more than 24 hours in advance and to show up for an appointment in a timely fashion.
• Where possible, to notify Provider at least 24 hours in advance of any appointment cancellations.
• To complete necessary consent, HIPAA, and other documents required by regulation or practice.
• If you want to participate in tele-health visits, to agree with and complete the Consent for Tele-Health consent services.
Communications and Privacy. The Provider and the Practice are concerned about Your privacy. The Provider will utilize in person communications, communications over the phone, and communications using the Hint Health patient portal to ensure safety in the communications. It is important that You understand up front that communications with the Provider using email, video, chat, instant messaging, and cell phones are not guaranteed to be secure. As mentioned in the prior section, You will be asked to sign a consent to utilize tele-medicine.
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 resolved in a court of proper venue and jurisdiction for the Practice. You agree to waive any right to have a jury participate in the resolution of any dispute or claim between the Parties which may arise under this Agreement.
Assignment. You may not transfer or assign this agreement, or Your rights under it, to any other person. Members Health Co may not assign this agreement to a successor medical practice.
Severability. If for any reason any provisions of this agreement are invalid or unenforceable, the validity of the remaining provisions will not be affected, and the invalid or unenforceable provision will be deemed modified to the minimum extent necessary to make it consistent with applicable law, and it will then be enforceable. If the agreement is invalidated, Practice has the right to offset any benefit conferred on You at fair market value against any refund owed You for fees.
PATIENT UNDERSTANDINGS (initial each):
______I understand I may cancel my membership at any time after the first 180 days with at least a 30-day notice. I further understand that upon termination of my membership, for any reason, pre-paid future monthly membership fees will be refunded within 30 days. For example, if in January I prepay for the entire year, and my membership terminates in April, the Practice will refund me the full amount I paid less four times my monthly periodic fee. I understand that fees are earned on the first of the month for the whole month, so my membership remains intact until the last day of the month that I cancel my membership.
______I understand that I must pay for each membership month with an auto-deduct option from an ACH bank account, or with a credit or debit card. This will be auto deducted on the last day of the month prior to the month that is being paid for. Otherwise, I will be billed on a yearly basis. If I choose to prepay for a year, I will receive a 5% discount. If I have not paid my membership fee for a given month, I will not be able to access any services until the account balance is paid.
______I understand this agreement and my membership covers only the ongoing primary care services described in Appendix 1 – Services Provided, and that this arrangement is not medical insurance.
______I understand I must pay for all medical services not included in Services Provided. Membership pricing for services provided outside of Members Health Co or established health partners can not be guaranteed.
______I am enrolling for membership in the Practice voluntarily. I understand I have other healthcare options.
______In the event of a medical emergency, I agree to call 911 first.
______I understand I will be required to pay all medical costs to the extent they are not covered services listed in Services Provided. I understand the Provider will make reasonable efforts to be available during clinic hours and after hours, but may not always be able to see me on a same-day basis. If medically necessary, I understand that I may be referred to a specialist, urgent care, or the emergency room for same-day service and in those circumstances I will have to pay for those services.
______I understand the Practice will not file or defend any insurance claims on my behalf and that I am prohibited from filing any claims or bills to insurance for services received.
______I understand this agreement does not meet the Affordable Care Act’s individual insurance requirement.
______I do NOT expect the Provider to prescribe chronic controlled pain medications or benzodiazepines.
______I understand that failure to pay the membership fee will result in termination from the Practice.
IN WITNESS WHEREOF, the parties have caused this Membership Agreement to be effective on the Effective Date first below written.
Patient Signature: __________________________________ Date: ________________
Patient Name: __________________________________
(Please Print)
APPENDIX 1
Services Provided
SERVICES: Summary of What You Can Expect From Your Membership.
Services offered. All services offered are made available according to the sole discretion of the Provider offering the services. If you have a problem that is more complicated than the provider feels comfortable caring for, they will discuss their concerns and help you come up with the safest option to care for the problem.
Medications. Our office offers wholesale-priced generic medications and over-the-counter medications that the Provider will dispense if medically indicated at Your cost, or will send to the pharmacy of your choice if You have insurance and prefer to use it. Medications can also be overnight shipped at Your cost, always in the most economical manner possible. In accordance with Tennessee State Law, we do NOT stock any controlled medications in our office.
Laboratory. Standard Membership includes annual comprehensive bloodwork (CBC, CMP, TSH/T4, Vitamin D, B12/folate, Urinalysis, Lipid panel), and a one-time food allergy panel at the beginning of Your Membership.
Premium Membership includes all of the Standard Membership bloodwork twice a year, and additional annual hormone and vitamin level testing (Total + Free Testosterone, Follicle-stimulating Hormone (FSH) and Luteinizing Hormone (LH), Cortisol, Lipoprotein(a), Lipid Panel with Apolipoprotein B (ApoB), GlycA (Inflammation), Diabetes Risk Index (DRI), Magnesium, Zinc, Coenzyme Q10, Ferritin).
All additional labs, including hormone levels, additional vitamin levels, and autoimmune testing are available at Your cost at a wholesale-priced discounted rate (for example, a Total + Free Testosterone level order would cost $45.76, compared to $128.70 at other primary care clinics since hormone levels are not routinely covered by insurance).
Imaging. If radiology imaging is medically indicated, we will schedule You at a Premier Radiology location of Your preference as quickly as possible. Our office has wholesale-priced discounted rates for all imaging services, including preventive screenings such as Mammograms.
Surgery and Specialist Referrals and Consults. Outside consults will be available at Your cost, requested only in consultation with You, and generally arranged as quickly as possible and in the most economical manner available.
Vaccinations. Vaccinations are NOT offered in our office at this time due to the cost prohibitive nature of stocking a limited supply. We will make an effort to help you obtain needed vaccinations elsewhere in the most cost-effective manner possible.
LIST OF SERVICES PROVIDED
Standard Membership
Basic Care
Wellness Exams
Sports Physicals
Preventive Care
Acute Care
Urinary Problems
Upper Respiratory Infections
Gastrointestinal Problems
Injuries (where office care is appropriate)
Small laceration repairs, except face, scalp and other areas the Provider deems inappropriate for an office procedure
Incision and removal of foreign body
Standard wound care
Complex Care
Diabetes Management
Hypertension Management
Hyperlipidemia (cholesterol) Management
Thyroid Disorder and Endocrine Management
Cardiovascular Disease Management
Pulmonary Disease Management
Gastroenterology Disease Management
Mental Health/Wellness Care
Hospital Follow-Up and Pre-Op Evaluations
Weight Management Planning
Premium Access
Same Day/Next Day Office Visits
Telemedicine Visits (email, phone, text, video chat)
Premium Membership (in addition to the above)
Personalized Care
NAD+ treatments included at no additional cost (either nasal spray or NAD+ shots at 50mg twice a week dose). Additional NAD+ or increased dosage subject to additional costs.
Monthly InBody 380 Body Composition Analysis - lean muscle, visceral fat, asymmetries, metabolic rate, inflammation
Personalized Diet & Exercise Health Coaching for Sustainable Health
House calls when medically necessary
Hospital advocacy - seeing you in the hospital if you are admitted
Personalized Weight Loss Management
Priority Access to our Wellness Membership (IV hydration, Botox, and Preventive Aging services)
APPENDIX 2:
Membership Fees
Standard Membership:
Age 12-49: $189 per month*
Age 50+: $225 per month*
Standard + Wellness Membership:
Age 12-49: $209 per month*
Age 50+: $245 per month*
Premium Membership:
Age 12-49: $379 per month*
Age 50+: $419 per month*
*If You prepay for a 12-month period, You receive a 5% discount.
*If You qualify for a discounted rate (self-employed, couple, musician, medical health worker, small business employee), You may receive a 10% discount. Multiple discount categories can not combine (eg. Musician + selfemployed). Prepay discount applies on discounted rate if applicable.