PATIENT AGREEMENT & DISCLOSURE STATEMENT TERMS
I acknowledge and understand that I am voluntarily becoming a Prepaid Urgent Care LLC (dba “DirectMedicalCare”) patient and that this agreement is non-transferable.
I have reviewed the DirectMedicalCare Patient Services guide and I have had the opportunity to ask questions and receive answers regarding its content.
I acknowledge and understand that this agreement does not provide comprehensive health insurance coverage nor is it a contract of insurance and that it provides only the health care services specifically described in the DirectMedicalCare Patient Services Guide.
I acknowledge and understand that I am responsible for any charges incurred for health care services performed outside of DirectMedicalCare including but not limited to emergency room, hospital and specialty services and that DirectMedicalCare will not bill insurance carriers for any services provided by DirectMedicalCare.
I acknowledge and understand that DirectMedicalCare must maintain a record of my health information and must protect the privacy of my health information as per the terms of the Notice of Privacy Practices. I understand and acknowledge that this policy is available for my review at any time at www.DirectMedicalCareUSA.com or upon request.”
I acknowledge and agree to pay my monthly care fee on or before its due date. In the event that I am unable to pay my fee(s) on time, I understand that I will be blocked from membership if I am not able to resume payments within a 7-day grace period.
I acknowledge and understand that I may terminate this Patient Agreement at any time and for any or for no reason by providing written notice to DirectMedicalCare. Monthly fees will continue to accrue until written termination notice is received. Any pre-paid monthly care fees will be prorated to the date DirectMedicalCare has received my written termination and refunded to me within ten (10) business days.
In addition, I acknowledge and understand that DirectMedicalCare may terminate this Patient Agreement by providing me written notice and any pre-paid monthly care fees will be prorated to the date of termination and refunded to me within ten (10) business days. DirectMedicalCare will not terminate this Patient Agreement solely on the basis of health status.
I acknowledge and understand that DirectMedicalCare may add or discontinue services or may increase my fee schedule at any time (but no more than once per year), and that I will be given, in writing, at least sixty (60) days notice of such fee schedule changes.
RIGHTS & RESPONSIBILITIES
I understand that I have the right to choose my personal health care clinician and to change my clinician at any time, for any reason. I understand that all reasonable efforts will be made to accommodate my request, but only if my new clinician’s patient panel is open to new patients.
I understand that I have the right to receive accurate and easily understood information about DirectMedicalCare’s health care services, health care professionals and health care facilities. If I speak a language different from my clinician, have a physical or mental disability or do not understand something, I understand that DirectMedicalCare will make its best effort to provide assistance so I can make informed health care decisions. If I require interpreter services beyond what can be provided by DirectMedicalCare, professional interpreters may be provided at an additional cost to me.
In the event of membership termination, I understand that I must complete a written Service Cancellation Form. Any differences in payment between my billing date and the date of cancellation will be refunded to me via the payment method I have chosen for my monthly care fee. I understand that if my account is overdue, I am responsible for resolving the outstanding balance prior to my service cancellation.
I understand that I have the right to considerate, respectful, and nondiscriminatory care from my DirectMedicalCare health care clinician (s). I also understand that I am responsible for communicating clearly and respectfully with my clinician. Should I become dissatisfied with my care or DirectMedicalCare services, I agree to notify DirectMedicalCare immediately so my concerns may be addressed in a timely manner.
I understand that I have the right to know all of my treatment options and to participate in my health care decisions. Parents, guardians, family members or other individuals whom I designate may represent me if I cannot make my own decisions.
I understand that I have the right to speak in confidence with my DirectMedicalCare provider(s) and to have my health care information protected. I understand that DirectMedicalCare will not disclose my information without my authorization or without a legal obligation to do so. I also understand that I have the right to review and receive a copy of my personal medical record and may request that my health care provider(s) amend my record if I feel it is inaccurate or incomplete by contacting the DirectMedicalCare Informatics Department.
I understand that I have the right to a fair, fast and objective review of any complaint I have against my health care clinician(s) or any other staff, including complaints about wait times, operating hours, conduct of personnel, business practices, and adequacy of health care services and facilities. I agree to first bring any complaints to the attention of DirectMedicalCare staff and to participate in the DirectMedicalCare complaint and grievance process.
In order to receive the best possible care, I agree to be actively involved in my health care decisions and to disclose all relevant information to my DirectMedicalCare health care clinician(s) so that they can help me achieve my health goals. I also agree to inform my DirectMedicalCare health care clinician(s) of any health care services I receive outside of DirectMedicalCare (such as emergency room, specialist, or hospital services).
I understand that I am responsible for not exposing myself or others to disease or danger. I understand that I can receive information from my DirectMedicalCare health care clinician(s) about protecting the health and safety of myself and others.
By my signature below at the end of this form, I agree to become a DirectMedicalCare patient and I agree to the terms outlined in this Patient Agreement.