SYNERGY COMPLETE HEALTHCARE
PATIENT AGREEMENT and TERMS OF SERVICE
This Patient Agreement is between SYNERGY COMPLETE HEALTHCARE
(the Practice, Us or We), and (Patient, Member, or You).
Background
The Practice, located at 1288 EISENHOWER RD, LEAVENWORTH, KS
provides ongoing primary care medicine to its Members in a direct pay,
agrees to provide You with the Services described in this Agreement under the
terms and conditions contained within.
membership model (DPC). In exchange for certain periodic fees, the Practice
Definitions
1. Services. In this Agreement, "Services" means the collection of services,
medical and non-medical, which are described in Appendix A (attached and
incorporated by reference), which We agree to provide to You under the
terms and conditions of this Agreement.
2. Patient. In this Agreement, "Patient," "Member," "You" or "Yours" means
the persons for whom the Practice shall provide care, who have signed this
Agreement, and/or whose names appear in appendix B (attached and
incorporated by reference).
Agreement
3. Term. This Agreement will last for one year, starting on the date it is fully
executed by the parties.
4. Renewal. The Agreement will automatically renew each year on the
anniversary date of the Agreement unless either party cancels the
Agreement by giving 30 days written notice.
5. Termination. Either party can cancel this Agreement at any time by giving
30 days' written notice to the other of intent to terminate.
6. Payments and Refunds – Amounts and Methods.
A. In exchange for the Services described in Appendix A, You agree to a
monthly payment (or Membership Fee) in the amount which appears in
Appendix C, which is attached and incorporated by reference;B. Upon Execution of this Agreement, You shall pay a one-time,
nonrefundable, Enrollment Fee, in addition to the Monthly Membership
Fee (which shall be prorated to the first or 15th of the month), in the
amount as described in Appendix C.
C. Thereafter, the Membership Fee shall be due on the first business day of
every month.
D. The Parties agree that the required method of payment shall be by
automatic payment through a debit or credit card or automatic bank
draft.
7. Early Termination. If You cancel this Agreement before its term ends, We
will refund any unused portion of your membership fee on a per diem basis.
8. Non-Participation in Insurance. The Practice does not participate with
any health plans, HMO panels, or any other third-party payor. As such, we
may not submit bills or seek reimbursement from any third-party payors
for the Services provided under this Agreement.
9. Medicare. The Patient understands that the Practice and staff [are opting
out/have opted out] of Medicare. As a result, both the Patient and the
Practice shall be prohibited by law from seeking reimbursement from
Medicare for any Services provided under this Agreement. Accordingly, the
Patient agrees not to submit bills or seek reimbursement from Medicare for
any such services. Furthermore, if the Patient is eligible or becomes
eligible for Medicare during the term of this Agreement, the Patient agrees
to immediately inform the Practice and sign the Medicare private contract
as provided and required by law.
10. This Agreement Is Not Health Insurance. The Patient has been advised
and understands that this Agreement is not an insurance plan. It does not
replace any health coverage that the Patient may have, and it does not
fulfill the requirements of any federal health coverage mandate. This
Agreement does not include hospital services, emergency room treatment,
or any services not personally provided by the Practice or its staff. This
Agreement includes only those Services identified in Exhibit A. If a Service
is not specifically listed in Appendix A, it is expressly excluded from this
Agreement. The Patient acknowledges that We have advised them to obtain
health insurance that will cover catastrophic care and other services not
included in this Agreement. Patients are always personally responsible for
the payment of any medical expenses incurred for services not included
under this Agreement.
11. Communications. The Practice endeavors to provide Patients with the
convenience of a wide variety of electronic communication options.Although We are careful to comply with patient confidentiality
requirements and make every attempt to protect Your privacy,
communications by email, facsimile, video chat, cell phone, texting, and
other electronic means, can never be absolutely guaranteed secure or
confidential methods of communications. By placing Your initials at the
end of this agreement, You acknowledge the above and indicate that You
understand and agree that by initiating or participating in the above
means of communication, you expressly waive any guarantee of absolute
confidentiality with respect to their use. You further understand that
participation in the above means of communication is not a condition of
membership in this Practice; that you are not required to initial this
clause; and that you have the option to decline any particular means of
communication.
12. Email and Text Usage. By providing an email address on the attached
Appendix B, the Patient authorizes the Practice and its staff to
communicate with him/her by email regarding the Patient's "protected
health information" (PHI). 1
By providing a cell phone number in Appendix
B and checking the "YES" box on the corresponding consent question, the
Patient consents to text message communication containing PHI through
the number provided. The Patient further understands and acknowledges
that:
A. Email and text message are not necessarily secure methods of
sending or receiving PHI, and there is always a possibility that a
third party may gain access;
B. Email and text messaging are not appropriate means of
communication in an emergency, for dealing with time-sensitive
issues, or for disclosing sensitive information. Therefore, in an
emergency or a situation that could reasonably be expected to
develop into an emergency, the Patient agrees to call 911 or go to
the nearest emergency care facility and follow the directions of
personnel.
13. Technical Failure. Neither the Practice nor its staff will be liable for any
loss, injury, or expense arising from a delay in responding to the Patient
when that delay is caused by technical failure. Examples of technical
failures: (i) failures caused by an internet or cell phone service outages; (ii)
power outages; (iii) failure of electronic messaging software, or email
outages of physician; (iv) failure of the Practice's computers or computer
network, or faulty telephone or cable data transmission; (iv) any
interception of email communications by a third party which is
unauthorized by the Practice; or (v) Patient's failure to comply with the
guidelines for use of email or text messaging, as described in this
Agreement.
1
As that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its
implementing regulations.14. Provider Absence. From time to time, due to such things as vacations,
illness, or personal emergency, the physician may be temporarily
unavailable. When the date/s of such absences are known in advance, the
Practice shall give notice to Patients so that they may schedule non-urgent
care accordingly. During unexpected absences, Patients with scheduled
appointments shall be notified as soon as practicable, and appointments
shall be rescheduled at the Patient's convenience. If during physician's
absence, the Patient experiences an acute medical issue requiring
immediate attention, the Patient should proceed to an urgent care or other
suitable facility for care. Charges from Urgent Care or any other outside
provider are not included under this Agreement and are the Patient's
responsibility. The Patient may, however submit such charges to their
health plan for reimbursement consideration or request that the outside
provider do the same. The Patient is responsible for understanding the
coverage rules of their health plan, and We cannot guarantee
reimbursement.
15. Dispute Resolution. Each party agrees not to make any inaccurate or
untrue and disparaging statements, oral, written, or electronic, about the
other. We strive to deliver only the best of personalized patient care to every
Member, but occasionally misunderstandings arise. We welcome sincere
and open dialogue with our Members, especially if we fail to meet
expectations, and We are committed to resolving all Patient concerns.
Therefore, in the event that a Member is dissatisfied with, or has
concerns about, any staff member, service, treatment, or experience arising
from their membership in this Practice, the Member and the Practice agree
to refrain from making, posting or causing to be posted on the internet or
any social media, any untrue, unconfirmed, inaccurate, disparaging
comments about the other. Rather, the Parties agree to engage in the
following process:
A. Member shall first discuss any complaints, concerns, or issues with
their provider;
B. The provider shall respond to each of the Member's issues or
complaints;
C. If, after such response, Member remains dissatisfied, the Parties shall
enter into discussion and attempt to reach a mutually acceptable
solution.
16. Monthly Fee and Service Offering Adjustments. In the event that the
Practice finds it necessary to increase or adjust monthly fees or Service
offerings before the termination of the Agreement, the Practice shall give 30
days' written notice of any adjustment. If Patient does not consent to the
modification, Patient shall terminate the Agreement in writing prior to the
next scheduled monthly payment.17. Change of Law. If there is a change of any relevant law, regulation or rule,
which affects the terms of this Agreement, the parties agree to amend it
only to the extent that it shall comply with the law.
18. Severability. If any part of this Agreement is considered legally invalid or
unenforceable by a court of competent jurisdiction, that part shall be
amended to the extent necessary to be enforceable, and the remainder of
the Agreement will stay in force as originally written.
19. Amendment. parties.
Except as provided within, no amendment of this Agreement
shall be binding on a party unless it is in writing and signed by all the
20. Assignment. Neither this Agreement nor any rights arising under it may
be assigned or transferred without the agreement of the Parties.
21. Legal Significance. The Patient acknowledges that this Agreement is a
legal document that gives the parties certain rights and responsibilities.
The Patient agrees that they are suffering no medical emergency and has
had reasonable time to seek legal advice regarding the Agreement and have
either chosen not to do so or have done so and is satisfied with the terms
and conditions of the Agreement.
22. Miscellaneous. This Agreement is to be construed without regard to any
rules requiring that it be construed against the drafting party. The captions
in this Agreement are only for the sake of convenience and have no legal
meaning.
23. Entire Agreement. This Agreement contains the entire Agreement
between the parties and replaces any earlier understandings and
agreements, whether written or oral.
24. No Waiver. Either party may choose to delay or not to enforce a right or
duty under this Agreement. Doing so shall not constitute a waiver of that
duty or responsibility and the party shall retain the absolute right to
enforce such rights or duties at any time in the future.
25. Jurisdiction. This Agreement shall be governed and construed under the
laws of the State of Kansas. All disputes arising out of this Agreement shall
be settled in the court of proper venue and jurisdiction for the Practice.
26. Notice. Written Notice, when required, may be achieved either through
electronic means at the email address provided by the party to be noticed
or through first-class US Mail. All other required notice must be delivered
by first-class US mail to the Practice at: 1288 EISENHOWER RD,
LEAVENWORTH, KS and to the Patient, at their address provided in
Appendix B.The Parties agree that throughout this agreement and it’s attachments,
checking the appropriate box next to their name will constitute an electronic
signature and shall be valid to the same extent as a handwritten signature.
APPENDIX A
SERVICES
1. Medical Services
Medical Services offered under this Agreement are those consistent with the
physician's training and experience, and as deemed appropriate under the
circumstances, at the sole discretion of the physician. The Patient is
responsible for all costs associated with any medications, laboratory testing,
and specimen analysis related to these Services unless otherwise noted
(Nextera will cover certain costs for their patients). The specific Medical
Services provided under this Agreement include the following:
• Acute and Non-acute office visits
• Chronic disease management (e.g. diabetes, high blood pressure, asthma,
heart disease)
• Preventive care
• Wellness visits
• Well-woman care
• Well-child care
• Sports physicals
• School physicals
• Consultation and/or coaching related to Weight loss, smoking cessation,
stress management, Healthy Lifestyle
• Sprains, Strains
• Skin biopsies and removal of skin tags, moles, benign skin lesions / warts
• Simple dermatology procedures and /or referral to dermatology
• Aspiration and/or injection of joints
• Abscess Incision and Drainage
• Minor Wound repair and sutures
• Ear wax removal
• Splinting
• Horizontal therapy
• Trigger point injection
• Pulmonary Function test
• EKG
2. Non-Medical, Personalized Services. The Practice shall also provide
Members with the following non-medical services:
• After-Hours Access. Subject to the limitations of paragraph 14,
Members shall have direct telephone access to the physician for
guidance in regard to urgent concerns that arise unexpectedly after
office hours.• Email Access. Subject to the limitations of paragraph 12, above,
The Patient shall be given the physician's email address to which
non-urgent communications can be addressed. The Patient
understands and agrees that neither email nor the internet should
be used to access medical care in the event of an emergency or any
situation that could reasonably develop into an emergency. The
Patient agrees that in this situation, when s/he cannot speak to the
physician immediately in person or by telephone, to call 911 or go to
the nearest emergency medical assistance physician, and follow the
directions of emergency medical personnel.
• Same Day/Next Day Appointments. When a Patient contacts the
Practice prior to noon on a regular office day to request a same-day
appointment, every reasonable effort shall be made to schedule the
Patient for that same day; or if this is not possible, Patient shall be
scheduled for the following office day (subject to the limitations of
paragraph 14).
• No Wait or Minimal Wait Appointments. Every reasonable effort
shall be made to assure that the Patient is seen by the physician
immediately upon arriving for a scheduled office visit or after only a
minimal wait. If physician foresees more than a minimal wait time,
Patient shall be contacted and advised of the projected wait time.
Patient shall then have the option of seeing the physician at the later
time or reschedule at a time convenient to the Patient.
• Telehealth. Telehealth (virtual visits) will be available when desired
and deemed appropriate by the Patient and physician.
• Specialists Coordination. The physician shall coordinate care with
medical specialists and other practitioners to whom the Patient needs
referral. The Patient understands that fees paid under this Agreement
do not include specialist's fees or fees due to any medical professional
other than the Practice staff.APPENDIX B
APPENDIX C
FEE ITEMIZATION
Re-enrollment fee.
If, after allowing membership to lapse or be terminated, Patient desires to re-
join the practice, the Patient shall be accepted on a space-available basis,
subject to a $ 50 re-enrollment fee (non-refundable).
Monthly Membership Fees
18 years and under* $ 10 per month X ____ Members $_______
19 to 64 years $ 60 per month X ____ Members $ _______
65+ years $ 75 per month X ___ Members $ _______
If membership has lapsed or is terminated, re-enrollment requires payment of
the re-enrollment fee
*18 years and under —$10 per month when enrolled with one adult in the
same household.
Total Monthly Membership Fee $ ________
Initial Payment
Prorated Membership Fees $ ________
______________________________________________________________________________
Total Due on Signing
$ ________
AUTOMATIC CREDIT/DEBIT CARD BILLING AUTHORIZATION
To enjoy the convenience of automated billing, simply complete the Credit/
Debit Card Information section below and sign the form. All requested
information is required. Upon approval, you will have the option to make
monthly payments or set up a monthly auto-deduction. Payments are made
directly through our secure link accessed through your electronic statement
sent to your email. Your statement will include monthly fees and incidental
charges which you will receive prior to any payments or deductions.
Customer(s)Name(s):________________________________________________________
__PAYMENT INFORMATION
I authorize Synergy Complete Healthcare to automatically bill the card listed
below as specified: Amount: $___________ for monthly subscription and
Incidental Charges;
Frequency:
Monthly Start billing on: ____/____/____
End billing when: Customer provides written cancellation
CREDIT/DEBIT CARD INFORMATION:
Credit card type: [ ] Visa, [ ] MasterCard, [ ] American Express, [ ] Discover
____________________ _________________________________ _____/_____
C
Introduction
The Balanced Budget Act of 1997 allows Providers to “opt out” of Medicare and enter into
private contracts with patients who are Medicare beneficiaries. In order to opt out, Providers
are required to file an affidavit with each Medicare carrier that has jurisdiction over claims that
they have filed (or that would have jurisdiction over claims had the Provider not opted out of
Medicare). In essence, the Provider must agree not to submit any Medicare claims nor receive
any payment from Medicare for items or services provided to any Medicare beneficiary for two
years. This Agreement between Beneficiary and Provider is intended to be the contract Provider
are required to have with Medicare beneficiaries when Providers opt-out of Medicare. This
Agreement is limited to the financial agreement between Provider and Beneficiary and is not
intended to obligate either party to a specific course or duration of treatment.
Provider Responsibilities
(1) Provider agrees to provide Beneficiary such treatment as may be mutually agreed
Upon and at mutually agreed upon fees.
(2) Provider agrees not to submit any claims under the Medicare program for any items
or services, even if such items or services are otherwise covered by Medicare.
(3) Provider agrees not to execute this contract at a time when Beneficiary is facing an
emergency or urgent healthcare situation.
(4) Provider agrees to provide Beneficiary with a signed copy of this document before
items or services are furnished to Beneficiary under its terms. Provider also agrees to
retain a copy of this document for the duration of the opt-out period.(5) Provider agrees to submit copies of this contract to the Centers for Medicare and
Medicaid Services (CMS) upon the request of CMS.
Beneficiary Responsibilities
(1) Beneficiary agrees to pay for all items or services furnished by Provider and
understands that no reimbursement will be provided under the Medicare program for
such items or services.
(2) Beneficiary understands that no limits under the Medicare program apply to amounts
that may be charged by Provider for such items or services.
(3) Beneficiary agrees not to submit a claim to Medicare and not to ask Provider to
submit a claim to Medicare.
(4) Beneficiary understands that Medicare payment will not be made for any items or
services furnished by Provider that otherwise would have been covered by Medicare if
there were no private contract and a proper Medicare claim had been submitted.
(5) Beneficiary understands that Beneficiary has the right to obtain Medicare-covered
Items and services from Provider and practitioners who have not opted out of Medicare,
and that Beneficiary is not compelled to enter into private contracts that apply to other
Medicare-covered items and services furnished by other Providers or practitioners who
have not opted out of Medicare.
(6) Beneficiary understands that Medigap plans (under section 1882 of the Social
Security Act) do not, and other supplemental insurance plans may elect not to, make
Payments for such items and services not paid for by Medicare.
(7) Beneficiary understands that CMS has the right to obtain copies of this contract upon
request.
Medicare Exclusion Status of Provider
Beneficiary understands that Provider has not been excluded from participation under the
Medicare program under section 1128, 1156, 1892, or any other sections of the Social Security
Act.Duration of the Contract
This contract becomes effective on _______________________, 2025. Either party may
terminate treatment with a 30-day notice to the other party. Notwithstanding this right to
terminate treatment, both Provider and Beneficiary agree that the obligation not to pursue
Medicare reimbursement for items and services provided under this contract will survive this
contract.
By _________________________________________________
Synergy Complete Healthcare
Patient’s Signature: _____________________________________ Date: _______________APPENDIX E
SERVICES/FEES NEXTERA
Initiation of this agreement will commence in the month during which a patient
has been assigned to Synergy Complete Healthcare by Nextera and the
following conditions have been met:
1: the patient has contacted Synergy Complete Healthcare
2. A sign-up agreement has been completed (online)
3. The patient has established contact with one of our providers.
Renewal terms are governed by our Standard Patient Agreement and align with
the contractual agreement between Nextera and Synergy Complete Healthcare.
Termination of this agreement will take effect at the end of the month in which
Nextera notifies us that a patient has either lost eligibility or has elected to
receive healthcare services elsewhere.
Patient account payments are also subject to the terms of the agreement
between Nextera and Synergy Complete Healthcare. However, patients may
incur charges for services not covered under Nextera’s plan, if such services are
considered beneficial or medically appropriate by the provider and are agreed
upon by the patient. Examples of non-covered services may include, but are
not limited to:
Vitamin B12 injections, NAD injections, Iv therapy for wellness (e.g.
glutathione, vitamin C, Meyer’s cocktail), weight management injections,
peptide injections, micro needling, PRP, facial peels.