Synergy Complete Healthcare
Patient Agreement
This is an Agreement between Synergy Complete Healthcare (Practice), a Kansas business located at 1288 Eisenhower RD, Leavenworth, Kansas 66048. Judith Beck FNP-BC, (Family Nurse Practitioner) in her capacity as an agent of Synergy Complete Healthcare and you, (Patient).
Background
The FNP, provides family healthcare services, delivers care on behalf Practice in Leavenworth Kansas. In exchange for certain fees paid by You, Practice, through its FNP(s), agrees to provide Patient with the Services described in this Agreement on the terms and conditions set forth in this Agreement.
Definitions / Sections
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 ongoing primary care services, both medical and non-Medical , and certain amenities (collectively “Services”) , which are offered by Practice, and set forth in Appendix 1 and 2. The Patient will be provided with methods to contact the provider via phone, email, and other methods of electronic communication. Provider 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. Fees. In exchange for the services described herein, Patient agrees to pay Practice, the amount as set forth in Appendix 1 and 2, attached. Applicable enrollment fees are payable upon execution of this agreement. If this Agreement is terminated by either party before the end of an applicable monthly period, then the Practice shall seek only partial payment for the final month of service based on the number of days of membership provided to the patient and the itemized charges, set forth in Appendix 2, for services rendered to Patient up to the date of termination.
4. Non-Participation in Insurance. Patient acknowledges that neither Practice, nor the Provider(s) participate in any health insurance or HMO plans. Neither the Practice nor Providers make any representations regarding third party insurance reimbursement of fees paid under this Agreement. 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 the agreement attached as Appendix 3, and incorporated by reference. This agreement acknowledges your understanding that Medicare cannot be billed for any services performed for you by the Provider. You agree not to bill Medicare or attempt Medicare reimbursement for any such services.
5. 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 personally provided by Practice, or its Provider(s). Patient acknowledges that Practice has advised that patient obtain or keep in full force such health insurance policy(ies) or plans that will cover Patient for general healthcare costs.
may need to visit the emergency room or urgent care from time to time. Provider will make every effort to be available at all times via phone, email, other methods such as “after hours” appointments when appropriate, but Provider cannot guarantee 24/7 availability.
6. Term. This Agreement will commence on the date it is signed by the Patient and Provider 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. Unless previously terminated as set forth above, at the expiration of the initial one-month term (and each succeeding monthly term), the Agreement will automatically renew for successive monthly terms upon the payment of the monthly fee at the end of the contract month. Examples of reasons the Practice may wish to terminate the agreement with the Patient may include but are not limited to:
(a) The Patient fails to pay applicable fees owed pursuant to Appendix 1 and 2 per this Agreement;
(b) The Patient has performed an act that constitutes fraud;
(c) The Patient repeatedly fails to adhere to the recommended treatment plan, especially regarding the use of controlled substances; (d) The Patient is abusive, or presents an emotional or physical danger to the staff or other patients of Practice; (e) Practice discontinues operation; and
(f) 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. Practice may also may terminate a patient without cause as long as the termination is handled appropriately (without violating patient abandonment laws).
7. Privacy & Communications. You acknowledge that communications with the Provider using e-mail, facsimile, video chat, instant messaging, and cell phone are not guaranteed to be secure or confidential methods of communications. The practice will make an effort to secure all communications via passwords and other protective means and these will be discussed in an annually updated Health Insurance Portability and Accountability Act (HIPAA) “Risk Assessment” which will be made available online (This is currently under revision and is subject to change) at www.synergycompletehealth.com/privacy. The practice will make an effort to promote the utilization of the most secure methods of communication, such as software platforms with data encryption, HIPAA familiarity, and a willingness to sign HIPAA Business Associate Agreements. This may mean that conversations over certain communication platforms are highlighted as preferable based on higher levels of data encryption, but many communication platforms, including email, may be made available to the patient. 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.
8. 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.
9. Reimbursement for Services if Agreement is Invalidated. If this Agreement is held to be invalid for any reason,
Associate Agreements. This may mean that conversations over certain communication platforms are highlighted as preferable based on higher levels of data encryption, but many communication platforms, including email, may be made available to the patient. 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.
8. 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.
9. Reimbursement for Services if Agreement is Invalidated. If this Agreement is held to be invalid for any reason, and if Practice is therefore required to refund all or any portion of the monthly fees paid by Patient, Patient agrees to pay Practice an amount equal to the fair market value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid.
10. Assignment. This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient.
11. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Kansas, and all disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for the Practice address in Leavenworth, Kansas.
12. Patient Understandings (initial each):
________ This Agreement is for ongoing primary care and is NOT a medical insurance agreement.
________ I do NOT have an emergent medical problem at this time.
________ In the event of a medical emergency, I agree to call 911 first.
________ I do NOT expect the practice to file or fight any third party insurance claims on my behalf.
_________I do NOT expect the practice to prescribe chronic controlled substances on my behalf. (These include commonly abused opioid medications, benzodiazepines, and stimulants)
_________In the event I have a complaint about the Practice I will first notify the Practice directly. This Agreement is non-transferable.
_________I am enrolling (myself and my family if applicable) in the practice voluntarily. I may receive a copy of this document upon request.
Name (or Guardian) Signature/Date Practitioner Signature/Date
________________________________________ ______________________________________________
APPENDIX 1 Synergy Complete Healthcare Periodic & Enrollment Fees
This Agreement is for ongoing primary care. This is Agreement is NOT HEALTH INSURANCE and is NOT A HEALTH MAINTENANCE ORGANIZATION. The Patient may need to use the care of specialists, emergency rooms, and urgent care centers that are outside the scope of this Agreement. Each Provider within the Practice will make an appropriate determination about the scope of primary care services offered by the Provider. Examples of common conditions we treat, procedures we perform, and medications we prescribe are listed on our website (www.SynergyCompleteHealth.com) and are subject to change.
Fee Schedule
Enrollment Fee – This is charged when the Patient enrolls with the Practice and is nonrefundable. This fee is subject to change. If a patient discontinues membership and wishes to re-enroll in the practice we reserve the right to decline re-enrollment or to require that the re-enrollment fee reflect an amount equivalent to the months of absent payments when dis-enrolled from the Practice.
Your Enrollment fee is $ 75.00
Monthly Periodic Fee (billed at the end of the service period) – This fee is for ongoing primary care services. Twenty scheduled in person visits per year are available to you at no additional cost. Each scheduled in person visit over twenty will be charged a $20 per visit fee. Your number of virtual visits (e-mail, electronic, phone) are not capped. We prefer that you schedule visits more than 24 hours in advance when possible. Some ancillary services will be passed through “at cost” (no markup by us). Examples of these ancillary services include laboratory testing, radiologic testing, and in office medications and these are described in Appendix B. Many services available in our office (such as EKGs) are available at significanly reduced cost to you. Items available at reduced cost will be listed on our website (www.SynergyCompleteHealth.com) and are subject to change.
The monthly periodic fee is $ 50.00 per month ages 19-64, $75 per month ages 65+, $10 per month ages 3-19 with a paying parent, $100 per month for homebound (due at the end of the month of service either on the 1st or 15th of the month, whichever date you choose). If your payment does not go through we reserve the right to re-attempt at a later date.
The patient is entitled to leave the practice at any time and be assigned a prorated final bill based upon the date of withdrawal from the practice.
After-Hours Visits
There is no guarantee of after-hours availability. This agreement is for ongoing primary care, not emergency or urgent care. Your provider will make reasonable efforts to see you as needed after hours if your provider is available.
Acceptance of Patients
We reserve the right to accept or decline patients based upon our capability to appropriately handle the patient’s primary care needs.