AHD Membership Agreement

This is an Agreement between ACCESS HEALTHCARE, P.A., LLC. (Practice), a NC Professional Corporation, located at 1031 W. Williams St. Suite 106 Apex NC 27502. (Physician) in his capacity as an agent of Access Healthcare, P.A.,. and you, (Patient).


The Physician, practices family medicine, delivers care on behalf Practice. In exchange for certain fees paid by You, Practice, through its Physician(s), agrees to provide Patient with the Discounted Services described in this Agreement on the terms and conditions set forth in this Agreement.

Definitions / Sections

1. Patient. A patient is defined as those persons for whom the Physician 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 discounts for 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 physician via phone, email, and other methods of electronic communication. Physician 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 at market value (non-discounted rate), 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 Physicians participate in any health insurance or HMO plans. In A DPC arrangement Physicians have usually opted out of Medicare. Patient acknowledges that federal regulations REQUIRE that Physicians opt out of Medicare so that Medicare patients may be seen by the Practice pursuant to a private direct primary care contract. Neither the Practice nor Physicians 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 Physician. 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 Physicians. 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. Patient acknowledges that THIS AGREEMENT IS NOT A

CONTRACT THAT PROVIDES HEALTH INSURANCE, and this Agreement is not intended to replace

any existing or future health insurance or health plan coverage that Patient may carry. This

Agreement is for ongoing primary care, and the Patient may need to visit the emergency room or

urgent care from time to time. Physician will make every effort to be available at all times via

phone, email, other methods such as “after hours” appointments when appropriate, but Physician

cannot guarantee 24/7 availability.

6. Term. This Agreement will commence on the date it is signed by the Patient and Physician 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


(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


7. Privacy & Communications. You acknowledge that communications with the Physician 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”

made available online (subject to change) at www.Genericdpc.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, 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

Wyoming and all disputes arising out of this Agreement shall be settled in the court of proper venue

and jurisdiction for the Practice address in Raleigh NC.

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.

Patient Name _____________________________________________

Patient (or Guardian) Signature _____________________________________________

Physician Name ______________________________________________

Physician Signature ______________________________________________


APPENDIX 1 Access Healthcare, P.A. 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 Physician within the Practice will make an appropriate determination about the scope of

primary care services offered by the Physician. Examples of common conditions we treat and

procedures we perform are listed on our website

www.acchealth.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


Your Enrollment fee is $99(paid with new membership or with renewal after not being a member for more than 30 days)

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 dispensed medications and these are described in Appendix B. Many services available

in our office (such as EKGs) are available at no additional cost to you. Items available at no

additional cost will be listed on our website (www.acchealth.com) and are subject to change.

The monthly periodic fee is $ 65.00 per month (due at the end of the month of service).

The periodic fee will be billed at the end of the month (after the ongoing primary care has been

provided) and 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 physician will make reasonable efforts to see you as needed after

hours if your physician 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. We may decline new patients pursuant to the guidelines

proffered in Section 6 (Term), because the Physician’s panel of patients is full (capped at 1,200

patients or fewer), or because the patient requires medical care not within the Physician’s scope of



Appendix 2 Access Healthcare, P.A. Itemized Fees

Ongoing Primary Care is included with the Periodic Fee described in Appendix 1. Please see a list of

some of the chronic conditions we routinely treat on the Practice website (subject to change)

(www.acchealth.com) There are no itemized fees for office visits unless the

patient has more than twenty scheduled in-office visits in a calendar year.

In-Office Procedures (subject to change) listed on the Practice website

(http://www.acchealth.com) are available at nominal or no cost.

Laboratory Studies will be drawn in the office at no additional charge and the Patient will be

charged the same rate the lab provides to the practice. An example of common laboratory studies

and their prices (subject to change) are listed on the practice website


Medications will be ordered in the most cost effective manner possible for the Patient. If we

dispense medications in the office these medications will be made available at wholesale cost

without any markup in price.

Pathology studies (typically skin biopsies) will be ordered in the most economical manner possible.

Anticipated prices for these studies (subject to change) are listed on the Practice website


Radiology studies will be ordered in the most cost effective manner possible for the Patient.

Surgery and specialist consults will be ordered in the most cost effective manner possible for the


Vaccinations are offered in our office at this time through Vaxcare. IF you have eligible insurance, then Vaxcare will charge your insurance for this vaccine and we will administer vaccine at no additional cost to you. IF you do not have eligible insurance then we will provide these vaccines at our cost.

Hospital Services are NOT inlcuded by our membership plan, and due to mandatory “on call” duties

required at local institutions we have elected NOT to obtain formal hospital admission privileges at

this time.

Obstetric and Gynecologic Services are NOT included by our membership plan. In the future we may

begin to offer some of these outpatient services in our office, but due to our small size we are

unable to offer these services at this time.


Appendix 3 Access Healthcare, P.A. Medicare Patient Understandings

This agreement is between Access Healthcare, P.A., and

Medicare Beneficiary: ___________________________________________________________

Who resides at: ___________________________________________________________

With Medicare ID #: _______________________________

Patient is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant

to Section 4507 of the Balanced Budget Act of 1997. The Practice has informed Beneficiary or

his/her legal representative that Physicians at the Practice have opted out of the Medicare program.


Physicians in the Practice have not been excluded from participating in Medicare Part B under

[1128] 1128, [1156] 1156, or [1892] 1892 of the Social Security Act.

Beneficiary or his/her legal representative agrees, understands and expressly acknowledges the



_____ Beneficiary or his/her legal representative accepts full responsibility for payment of the

physician’s charge for all services furnished by the physician.

_____ Beneficiary or his/her legal representative understands that Medicare limits do not apply to

what the physician may charge for items or services furnished by the physician.

_____ Beneficiary or his/her legal representative agrees not to submit a claim to Medicare or to ask

the physician to submit a claim to Medicare.

_____ Beneficiary or his/her legal representative understands that Medicare payment will not be

made for any items or services furnished by the physician that would have otherwise been covered

by Medicare if there was no private contract and a proper Medicare claim had been submitted.

_____ Beneficiary or his/her legal representative enters into this contract with the knowledge that

he/she has the right to obtain Medicare-covered items and services from physicians and

practitioners who have not opted out of Medicare, and the beneficiary is not compelled to enter into

private contracts that apply to other Medicare-covered services furnished by other physicians or

practitioners who have not opted out.

_____ Beneficiary or his/her legal representative understands that Medi-Gap plans do not, and that

other supplemental plans may elect not to, make payments for items and services not paid for by


_____ Beneficiary or his/her legal representative acknowledges that the beneficiary is not currently

in an emergency or urgent health care situation.

_____ Beneficiary or his/her legal representative acknowledges that a copy of this contract has been

made available to him.

Executed on:

By: _______________________________

Medicare Beneficiary or his/her legal representative

And: _______________________________

On behalf of Access Healthcare, P.A., LLC