CapstoneMD TotalCARE Agreement
This TotalCARE AGREEMENT ("Agreement") is entered into on (TBD) (the “Effective Date”) by and between CapstoneMD, LLC (“CMD”) and the undersigned individual (“Patient”).
WHEREAS, Drs. Paul and Jeff Davis (collectively, the “Doctors”), together with their team of licensed healthcare providers and any alternate physician ever designated by CMD (collectively, the “Team”), have designed a program to make healthcare provider-patient contact more readily available to a select number of patients, and
WHEREAS, Patient desires to enroll in CMD’s physicians’ TotalCARE program.
NOW THEREFORE, the parties agree to the following terms and conditions:
1. Contract Year; Renewal; Termination
a. This Agreement commences on the Effective Date and continues for a period of 12 months unless terminated early as provided under Section 1(b). Upon expiration of the initial 12 month period, this Agreement will automatically renew for successive periods of twelve 12 months each, unless this Agreement is terminated earlier under Section 1(b) or is cancelled in advance for the next Contract Year by either party giving at least 60 days prior written notice to the other party before the end of the applicable Contract Year. The initial 12 month period and each successive 12 month period following the anniversary of the Effective Date are referred to as a “Contract Year.”
b. Either party may terminate this Agreement for any reason at any time with 30 days prior written notice delivered to the other party. Further, if Patient fails to timely and fully pay the Annual Fee (defined below), CMD may terminate this Agreement effective immediately on delivery of written notice to Patient. If either party terminates this Agreement for any reason, Patient will be entitled to a refund of a prorated portion of the Annual Fee based on the number of then remaining unused prepaid months.
2. TotalCARE Plan.
a. CMD will provide physician and healthcare provider access to each Participant as follows:
- Initial consultation and comprehensive health risk assessment
- 24 hours per day/7 days per week/365 days per year access to the Doctors and/or the Team via telephone, text, secure internet patient portal, or email-Same business day or next business day office appointments following the time when Participant contacts CMD requesting an appointment
- No or minimal waiting time in Office Waiting Room
- Personalized and prioritized referrals to specialists as necessary
- Secure online access to personal medical records
- Online consultation via e-mail
- House calls as deemed appropriate by the Team (Additional fees may apply)
- Priority management of hospitalization at hospital of Patient’s choice
- Portable digital personal medical record
- Interactive Capstone.MD website for timely information and updates
- CMD-TotalCARE card for quick reference and identification
b. In addition to all the "TotalCARE" benefits, the following services, delivered at the CMD's
office, will also be covered by the fee:
- Annual and “as needed” health risk assessment
- Acute and preventive care visits at CapstoneMD offices (excluding obstetrics)
- No billing, co-pays or deductibles at the time of the visit
- All routine lab, pap smear, x-rays and immunizations (excluding overseas immunizations)
- Routine ultrasound as indicated (excluding obstetric)
- Stress EKG if appropriate
- DEXA scan every 2-3 years if appropriate
- Body fat analysis
- Skin cancer screening & removal of suspicious lesions (pathology charge not included)
SERVICES NOT COVERED:
- services performed by practitioners other than CapstoneMD Team
- ongoing clinical services such as behavioral counseling, PT, OT, speech therapy
- any services related to pregnancy or infertility
- prescription medications
- medical devices
- cosmetic or aesthetic services
- emergency response, diagnosis, transport or treatment
- services are limited ONLY to those which are provided in CMD offices and as listed above
c. The terms “Participant” or “Participants” means Patient and Patient’s immediate family members listed on the attached Exhibit A. Each Participant is responsible for honoring all of the terms and conditions of this Agreement.
3. Annual Fee; Payment Terms.
Payment can be made by monthly bank draft which will be executed for a full 12 months. However if Patient agrees to pay in advance the applicable annual fee (the “Annual Fee”) for each Contract Year they will receive one month of free service.
The initial Annual Fee will be (TBD). The Annual Fee for each subsequent Contract Year will be the then current rate being charged by CMD.
The initial Annual Fee or agreement for monthly bank draft is due upon execution of this Agreement. For each subsequent Contract Year, the applicable Annual Fee is due thirty (30) days prior to the first day of the applicable Contract Year. CMD may charge a late fee equal to the highest rate allowed by law for all over due unpaid amounts.
Patient will immediately notify CMD if any Participant is or becomes a recipient or beneficiary of Medicare, Medicaid or any other government healthcare program.
After the first Contract Year, CMD reserves the right to modify the Annual Fee or the Participant service categories for any reason determined in CMD’s sole discretion, provided CMD will give Patient at least 60 days prior notice of the newly revised Annual Fee before the applicable Contract Year begins.
Each Participant is individually bound and liable for honoring this Agreement.
Each Participant will be able to contact CMD by telephone, text messaging, email and secure patient portal (“SPP”). For after-hour access, Participant may contact CMD via cell phone, text messaging, SPP or email. Participant agrees that email or text messaging are not appropriate for urgent or time sensitive communications. If time sensitive, a Participant must contact CMD by telephone at CMD’s designated phone number. If Participant does not receive a response to any email within two days following its transmission, Participant must use another authorized means to contact CMD. Email, phone calls, and text communications may, at the discretion of CMD, become part of a Participant’s permanent medical record.
Patient acknowledges that email, texts and cell phones are not always secure mediums for sending or receiving sensitive personal health information and that confidentiality cannot be assured or guaranteed. Nevertheless, Participant authorizes CMD to communicate with Participant regarding “protected health information,” as that term is defined in the Health Insurance Portability and Accountability Act, using the email addresses, text and cell phone numbers provided by Participant.
5. Limitations of Access.
Patient understands that due to the nature of their medical practices, the Doctors may at times be busy tending to other patients or otherwise unavailable, and therefore, may not always be able to answer or immediately respond. Likewise, the Doctors may not always be able to personally respond. The Doctors and the Team will attempt to respond to the Participants as quickly as reasonably possible. Participants must hold CMD, the Doctors and Team harmless from any claims, liabilities, costs, damages, expenses or consequences resulting from their failure to respond to Participants in a timely manner.
Patient acknowledges that either or both of the Doctors may also be periodically absent for
vacations and continuing medical education, or could be also be unavailable due to illness,
temporary disability, or other personal or family emergencies. In such cases, CMD may
designate an alternate physician or licensed healthcare provider to communicate with
7. Emergency Medical Treatment.
Neither CMD’s medical offices are, nor will any other subsequently designated location be, an emergency medical center. If a Participant has a serious medical emergency, the Participant must call “911” (or other appropriate emergency contact number) or seek services directly from a hospital or urgent care facility.
Participants are responsible for obtaining medical insurance coverage. CMD is not responsible for enrolling the Participants in any applicable Medicare program. None of the Access Services described here-in are reimbursable by commercial insurance, Medicare, Medicaid or any other government insurance program.
Receipts for services rendered in the Office for preventive or illness care will be submitted to Participant whose responsibility is to file with insurance plan and or HSA plans for credit.
9. Compliance with MPMD Rules and Procedures.
CMD may, from time to time, establish or post rules or procedures (“Contact Rules”) for the Participants to follow in terms of contacting, or having access to, CMD, the Doctors or the Team. Patient agrees that all Participants will comply with all such rules and procedures, as they may be created or amended by CMD in its sole discretion from time to time.
a. Entire agreement; Amendments.
This Agreement plus the Contact Rules contain the entire understanding of the parties. This Agreement cannot be unilaterally amended by Patient or any Participant.
b. Assignment of Agreement.
This Agreement is binding on the parties and their respective heirs and legal representatives. Participants may not assign this Agreement.
This Agreement will be subject to and governed by the laws of the State of Kansas.
Patient and CMD each agree to submit any dispute arising under this Agreement, including the manner, effectiveness or result of any professional services rendered to mediation under the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Mediation. If any dispute is not resolved by mediation within 90 days after mediation begins, either party may submit the dispute to binding arbitration in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration. The same person may not serve both as the mediator and the arbitrator.
d. Legal Capacity or Authority to Contract.
Participant represents and warrants that he or she has full capacity, authorization, authority and ability to enter into this Agreement on his or her own behalf and the current Participants and any future Participant Patient may enroll.
e. Delay or Frustration.
CMD will not be liable for any delay or failure to perform due to any cause beyond its reasonable control. Any delay will excuse performance, as may be reasonable in light of the circumstances.
The parties have executed this Agreement effective as of the Effective Date.
It is strongly suggested that this plan be used along with and not instead of a standard Health Insurance Plan. THIS IS NOT AN INSURANCE PLAN. This only covers in-office care at CapstoneMD offices.
Please contact CMD’s offices before enrolling if you have any questions.