JUBILEE CLINIC, LLC
DIRECT PRIMARY CARE
MEMBER MEMBERSHIP AGREEMENT
Jubilee Clinic, LLC (“Practice”) and _________________________, (“Member”) enter into this Direct Primary Care Membership Agreement (“Membership Agreement”) with the Effective Date as stated in Section 1(c) for Member to become a member of Practice’s Direct Primary Care Program. Practice and Member are referred to herein collectively as the “Parties.”
1. Membership, Program Services and Enrollment.
a. Program membership. Once enrolled into the Program as a member by completing all of the steps outlined in Section 1c, Member shall be eligible to receive certain primary care medical services (“Program Services”) provided by Practice. Practice may add or discontinue a service in its sole discretion by emailing or regular mail at least thirty (30) days prior to the change.
b. DPC; Not Concierge. This Agreement is for membership in Practice’s Direct Primary Care (“DPC”) Program and is not an agreement for membership in a concierge program. The difference between DPC and concierge is that DPC provides Member with certain primary care medical services for the payment of a flat monthly fee. Concierge, on the other hand, involves Member’s payment of a flat monthly fee to obtain immediate or priority access to a physician but does not cover the cost of any medical services; Member’s insurance is billed for these medical services. Accordingly, while this Membership Agreement will provide after-hour access to Member’s provider via telecommunications and provide Member with an office visit during normal business hours for acute issues, Member will not be entitled to an immediate office visit or access to his or her provider whenever Member so desires.
c. Enrollment and Effective Date. Member may enroll into the Program on any day of the month by utilizing Practice’s onboarding link to submit the required personal and billing information for autopayment of fees and sign this Agreement and any other required documents. This Agreement becomes effective on the date the Member completes all of the aforementioned enrollment requirements.
d. Location. Member shall receive Program Services at 1519 9th St, #103, Marysville, WA98270
2. Fees.
a. Enrollment Fee/Re-enrollment Fee. Each Member shall pay a one-time, non-refundableenrollment fee to cover the costs associated with Member’s initial enrollment into the Program (“Enrollment Fee”).
The Enrollment Fee shall be:
– Ninety dollars ($90.00) for each individual Member and no more than one-hundred and eighty dollars ($180.00) per household for enrollment at the same time. In the event a Member terminates this Membership Agreement for any reason, Member will be ineligible to re-enroll in the Program for a period of six (6) months following the effective date of termination. Notwithstanding the preceding sentence, Practice, in its sole discretion, may allow Member who has terminated their Membership Agreement to re-enroll before the six (6) month period has passed. Any re-enrollment after termination will require Member to pay a re-enrollment fee in the amount of ninety dollars ($90.00) and sign a new Membership Agreement.
b. Monthly Membership Fee. In addition to the one time Registration Fee, each Member shall pay a Monthly Membership Fee (“MMF”) according to the fee schedule.
– One hundred fifteen dollars ($115.00) for each individual Member ages 50+.
– Eight-five dollars ($85.00) for each individual Member ages 35-49.
(Married couples under 21 and dependents not enrolled with a parent pay this price.)
– Seventy dollars ($70.00) for each individual Member ages 19-34.
– Forty dollars ($40.00) for each individual Member ages 0-18 for the first two children, ten ($10)
for each additional child.
c. Additional Fees. Only for supplies provided, medications, and specific vaccines provided.
d. Changes to Fees. Practice may change the amount of the Registration Fee, the MMF, and the additional fees described above, or any other fees associated with this Membership Agreement at any time but not more frequently than annually, in its sole discretion, upon providing Member at least sixty (60) days’ advance notice by either emailing Member or sending them notice in the mail.
3. Automatic Payment of Membership Fees.
a. Auto Payment Information and Changes. During the enrollment process discussed in Section 1.c, Member will input their bank account/debit/credit card information so that MMF payments may be made automatically. Member may change or update payment information by accessing his or her account using Practices online, onboarding and billing platform. Please contact the clinic for digital access to your billing portal.
b. Authorization. By inputting this information or by changing/updating bank account/debit/credit card information during the term of this Agreement, Member is providing Practice with authorization to have its online, onboarding and billing platform initiate MMF recurring charges every month. This authorization will remain in full force until this Agreement is terminated in accordance with Section 14 and until Practice and Member’s debit/credit card institution has a reasonable time to act on it.
c. Appearance for Recurring Auto Payments. The MMF auto charge or debit will appear on card holder or Member/authorized signor’s bank statements as Story Family Medicine, or a variation of this name.
d. Timing of Auto Payments. Payment for the first month of services will be due upon enrollment. Thereafter, auto payments will be processed every thirty days from the date of Member’s enrollment as discussed in Section 1c.
e. Auto Payment Failure/Late Fees. In the event an auto payment fails for any reason, Members will receive an email with a link to update the credit card/bank account information. If this information is not updated within 14 days from when the payment was due, Practice will contact Member to obtain updated credit card/bank account information and collect a late payment fee of thirty-five dollars ($35.00).
4. No Insurance Claims. Practice will not bill any insurance carriers or health care plan to which Member may be a subscriber or beneficiary for the MMF or any additional fees associated with Membership and the Program Services. Member is solely responsible for payment for all Services Member receives from Practice regardless of whether such Services are reimbursable or payable by Member’s insurance carrier. Any amounts due for additional
fees that are not included in the MMF will be paid by Member at the time the services are rendered.
5. No Reimbursement from Government Healthcare Programs. Practice and its providers have opted out of participation in all governmental healthcare programs (including, but not limited to Medicare, Medicaid, TRICARE, CHIP, VHA, and Indian Health Service). This means that Practice cannot bill any of these government healthcare programs on behalf of Member, nor can Member make any attempt to collect reimbursement from any of these programs.
6. Member Requirements When Medicare Part B Beneficiary. Any Member that is a Medicare Part B Beneficiary will need to notify Practice of this fact and will be required to sign Practice’s Medicare Private Contract prior to receiving any services. Failure to do so shall cause Member to be terminated from the Program.
7. Tax-Advantaged Medical Savings Accounts. Member may have a tax-advantaged savings account, including, but not limited to, a health savings account, medical saving account, flexible spending arrangement, health reimbursement arrangement, or other similar health plan (collectively, “Tax-Advantaged Savings Accounts”). Because every Tax-Advantaged Savings Account is unique, Member is advised to consult with their accountant regarding whether any of the fees incurred pursuant to this Membership Agreement may be paid using funds contained in a Tax-Advantaged Savings Account.
8. Other Insurance; High Deductibles. Some services provided herein may be a covered benefit or covered service, at no cost to Member, under Member’s health benefit plan. Further, third-party payers may not count the Membership Fees incurred pursuant to this Membership Agreement or the fees associated with additional services that are not included in the MMF toward any deductible Member may have under a high deductible health plan. Member should consult with their health benefits adviser regarding whether Membership Fees may be counted toward Member’s deductible under a high deductible health plan.
9. No Emergency Care. Practice is not an emergency room, and accordingly, does not have the ability to treat Member during a medical emergency. If Member is experiencing a medical emergency, Member should contact 911 or go to the nearest emergency room to seek immediate treatment.
10. Virtual Visits. Virtual visits are included in the MMF but are at the sole discretion of Practice as there are times when a virtual visit is not suitable given the situation, which will require Member to schedule an in-person appointment for treatment.
11. First Visit and Annual Wellness Visit. While the Program Services include virtual visits, Member’s enrollment requires that Member schedule an appointment to be seen in person by Practice for an initial assessment/establish care visit within thirty days of enrollment in the Program. Thereafter, Member agrees to physically visit Practice for an annual wellness visit at least once per year following the anniversary of the Effective Date.
12. HIPAA and Communications. Practice shall comply with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requirements including the privacy regulations, security standards and the standards for electronic transactions. Member’s participation in the Program and execution of this Agreement will provide Member with the ability to communicate with the Practice through the use of an encrypted portal. If Member would like for Practice to communicate with Member outside of this encrypted portal, such as by regular e-mail, texting and cell phone, Member will be required to execute the Consent to Unencrypted Email and SMS Messaging of PHI. This will authorize Practice and its staff to communicate with Member by email and cell phone regarding Member’s “protected health information” (PHI). E-mail is not an appropriate means of communication in an emergency for dealing with time-sensitive issues. In an emergency, or a situation in which could reasonably be expected to develop into an emergency, Member understands and agrees to call 911 or go to the nearest hospital as opposed to emailing Practice or leaving a cell phone message.
13. Term. This Agreement shall become effective on the date discussed in Section 1(c) above and shall continue on a month-to-month basis until terminated in accordance with Section 1.
14. Termination.
a. Termination by Member. Member may terminate this Membership Agreement by completing the Written Notice of Membership Termination Form (“Term Form”) which is available by contacting Practice. This Form may be submitted to Practice either in person or by email to: office@jubileeclinic.com.
b. Term Form Timing Requirements. All Term Forms must be received by Practice no later than thirty (30) days prior to Member’s next bank account/credit/debit auto-processing date. Member shall be responsible for verifying with Practice that his or her Term Form was received by Practice 30 days in advance of Member’s next auto billing date. Term Forms submitted within the 30-day billing cycle will result in a final MMF auto payment, enabling Member to utilize the Program Services for another 30 days. No refund will be issued once an auto payment is made.
c. Termination by Practice. Practice may terminate this Agreement if Member:
a) fails to pay his or her Membership fees;
b) performed an act of fraud;
c) repeatedly fails to adhere to the recommended treatment plan;
d) violates Practice’s Code of Conduct or is abusive and presents an emotional or physical danger to the staff or other Member of the Practice; or
e) has healthcare needs that exceed the care that can be provided under the Program. No refunds will be provided.
15. Code of Conduct. In order for Practice to provide a safe and healthy environment for staff, Member and their families, Practice expects Member and accompanying family member or friends to refrain from unacceptable behaviors that are disruptive or pose a threat to the rights or safety of other Member or staff. Accordingly, as a condition of membership in the Program, Member agrees to execute a copy of the Practice’s Code of Conduct as part of the onboarding process. Any violation of this Code of Conduct by Member or their accompanying family
member or friends will result in Member’s immediate termination from the Membership Program.
16. Indemnification. Member agrees to indemnify and to hold Practice and its member, 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 Practice as a result of Member’s breach of any of Member’s obligations under this Membership Agreement.
17. Technical Failure. Neither Practice nor any Provider will be liable for any loss, injury, or expense arising from a disruption or delay in responding to Member when the disruption or delay is caused by technical failure. Examples of technical failures include: (i) failures caused by an internet or cell phone service provider; (ii) power outages; (iii) failure of electronic messaging software, or any email provider; (iv) failure of Practice’s computers or computer network, or faulty telephone or cable data transmission; or (iv) any interception of email communications by
a third party which is unauthorized by Practice.
18. Entire Agreement. This Membership Agreement constitutes the entire understanding between the Parties hereto relating to the matters herein and shall not be modified or amended except in a writing signed by both Parties hereto.
19. Waiver. The waiver by either Practice or Member 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 Practice or Member.
20. Change of Law. If there is a change of any law, regulation or rule, federal, state or local, which affects this Membership Agreement, any terms or conditions incorporated by reference in this Membership Agreement, the activities of Practice under this Membership Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and Practice reasonably believes in good faith that the change will have a substantial adverse effect on Practice’s rights, obligations or operations associated with this Membership Agreement (a “Legal Change”), then Practice may, upon written notice, require Member to enter into good faith negotiations to renegotiate the terms of this Membership Agreement. If the parties are unable to reach an agreement concerning the modification of this Membership Agreement within ten (10) days after the effective date of the Legal Change, then Practice may immediately terminate this Membership Agreement upon providing written notice to Member.
21. Appendices and Documents. The Appendices referenced in this Agreement, together with all the documents referenced herein, form an integral part of this Agreement, and are incorporated into this agreement wherever reference is made to them to the same extent as if they are set out in full at the point at which such reference is made.
22. Assignment. This Membership Agreement shall be binding upon and shall insure to the benefit of the Practice and its respective successors and legal representatives. Neither this Membership Agreement, nor any rights hereunder, may be assigned by Member without the written consent of Practice.
23. NOT INSURANCE. PER RCW 48.150, THIS AGREEMENT DOES NOT PROVIDE COMPREHENSIVE HEALTH INSURANCE COVERAGE. IT PROVIDES ONLY THE HEALTH CARE SERVICES SPECIFICALLY DESCRIBED.
IN WITNESS WHEREOF, the Parties have caused this Membership Agreement to be effective
in accordance with Section 1(c) herein.
_______________________________________
MEMBER SIGNATURE:
If Member is a minor, then name and signature of Member’s parent or legal guardian
_______________________________________
Name of Member’s Parent or Legal Guardian
Appendix A MONTHLY MEMBERSHIP PROGRAM SERVICES
Appointments. All appointments will be at the discretion and scheduling of Practice. Practice does not provide walk-in urgent care services. Practice strives to see Member in a timely manner during normal business hours, which are: Monday through Thursday from 8:30 am – 5:00 pm, with a lunch break between 1:00 and 2:00 pm and Friday 8:30 am – 12:30 pm. Same-day appointments are subject to provider’s availability. The last appointment of the day is at 4:30 pm. Wellness visits and appointments for Member new to the Practice, which typically take more time, are subject to the provider’s availability. For Member with acute issues, same or next-day care shall be available depending on whether it’s medically necessary and the provider’s availability.
After-hour Communications. Outside of normal business hours, Member may call or message Practice’s provider everyday including holidays and weekends. Practice’s provider will make every effort to address Member’s medical needs in a timely manner, but Practice cannot guarantee provider’s availability, and cannot guarantee that Member will not need to seek treatment in an urgent care or emergency department setting. Calls or messages outside of
normal hours are reserved for urgent/acute clinical concerns only. Appointment requests, prescription refills, Program questions and routine health care concerns or questions will not be addressed outside of normal business hours. Routine or continued disregard of this requirement may result in termination of Member’s membership in the Program.
Emergency Care. In an emergent situation, or anything that could possibly be perceived as an emergent situation, Member should proceed to the nearest emergency room or call 911.
Alternative Provider. In the event Member’s provider is on vacation or is unavailable either in person or via telecommunications, an on-call provider will be available.
Labs. Labs are not included in the monthly membership fees. Member may elect to use their private insurance for laboratory testing; Practice is not responsible for costs incurred with insurance-billed testing.
Medications. Medications dispensed in the office are not included in the membership fee and the cost will be due at the time they are dispensed. Member’s membership in the Practice does NOT guarantee medications will be prescribed or that certain medications will be provided to Member; Practice’s physician will do what is medically appropriate for the Member in determining whether to prescribe medications. Practice does not dispense controlled medications, and reserves the right to not prescribe controlled substances, including stimulants,
opiates, and benzodiazepines.
Durable Medical Equipment (DME). DME is equipment utilized in a Member’s treatment. Practice maintains a supply of some DME equipment for loan, but does not guarantee availability. Practice will advise Member as to what DME is required and how to obtain the DME. If DME is provided to Member by the Practice, the cost is not included in the membership fee, and will be due at the time the DME is provided.
Pathology. Pathology testing of tissue samples collected from procedures is not included in the membership fee.
Imaging and Testing. Outside imaging services (for example, Xray’s, MRI, CT Scans, Ultrasounds) and outside testing (for example, cardiac, pulmonary, GI studies) are not included in the membership fee and will be ordered in an economical manner. Imaging is either arranged with payment directly to the outside facility or client-billed on behalf of Member. Member will be invoiced if the Practice receives a bill.
Referrals. Practice’s physician will make recommendations for outside referrals when medically necessary. Practice will make every effort to work with Member to choose the most appropriate service provider based on skill, geographical location, and cost-effectiveness
