Concierge Services Member Agreement
THIS AGREEMENT DOES NOT PROVIDE COMPREHENSIVE HEALTH INSURANCE COVERAGE. IT PROVIDES ONLY THE SERVICES SPECIFICALLY DESCRIBED HEREIN AND IT PROVIDES ONLY A LIMITED NUMBER OF THESE SERVICES. WHILE IT OFFERS MANY OF THE BENEFITS OF PRIMARY CARE IT IS NOT A PRIMARY CARE PLAN NOR A SUBSTITUTE FOR PRIMARY CARE. PRAVAN MEMBERSHIP IS ALSO NOT AN INSURANCE PLAN NOR AN INSURANCE COMPANY.
Pravan Health, LLC
Concierge Services Member Agreement
This Concierge Services Member Agreement (the “Agreement”) is entered into and effective as of the date of submission of this Agreement (“Effective Date”) by and between the person signing below (“You” or “Member”) and Pravan Health, LLC. (“Pravan”).
By signing this document, You hereby consent to all the terms and conditions in this Agreement as of the Effective Date.
Pravan provides medical services to Members and contracts physicians and/or practitioners for the purpose of providing the services defined in this Agreement in exchange for a fee (“Pravan Physician”). Pravan shall provide to Members greater access to their physicians and certain limited health care services focused on wellness and prevention, with an innovative membership-based personalized healthcare program. Pravan provides a broad range of personalized services, creating a meaningful Member experience to help Member achieve their optimal health and wellbeing.
The purpose of this Agreement is to set forth the terms and conditions of how the Services will be furnished to You. You and Pravan therefore agree as follows:
Pravan, thru its physicians, will provide You with the Medical Services described in this Section. As used in this Agreement, the term Medical Services means only those medical services that the Physician is permitted to perform under the laws of the Commonwealth of Puerto Rico and that are consistent with his/her training and experience as a physician. Generally, such services encompass health promotion, disease prevention, diagnosis, care and treatment of patients during health and other stages of illness with a focus on preventive care. Non-Medical Services shall also be provided by Pravan. See attached Exhibit I.A for all Medical and Non-Medical Services that are included in the Membership Fee and those that are available to Member for an additional fee (Fee for Service, Exhibit I. B.).
Your Membership Fee shall cover and include the services detailed under Membership Fee Services only for You, as a member. Services outside your Membership Fee are detailed in Exhibit I under Additional Available Services. Additional Available Services shall be charged at a fee-for-service charge in addition to your Membership Fee. Your Membership Fee does not cover Additional Available Services, and you may incur additional out of pocket costs for: hospitalization, surgical procedures, vaccines, medications, elective injectables, X-rays, any diagnostic testing or lab work, pathology, emergency room visits, prenatal care, and other services not typically rendered by primary care physicians in their medical offices. You will be responsible for payment of all medical costs not covered by your Membership Fee. Also, not all conditions can be treated by Pravan, and at times, additional medical care may be required.
The Membership Fee covers only the defined Services described in Section 1 of this Agreement. Pravan Physician, Tania Rivera, MD has Opted out of Medicare. The defined Services are not covered, in whole or in part, by private health insurance or third party payment programs providing health related benefits (including Medicare or any other Government payor) (collectively “Payors”). You represent and agree that the Services and the Membership Fee shall not be billed to any Payors and shall not be reimbursable to Member by any Payors. Neither You nor Pravan shall submit a bill nor seek reimbursement or payment from any Payors for any portion of the Membership Fee or Services covered by the Membership Fee. Member or their legal representative accepts full responsibility for payment of all charges of furnished Services.
You agree and consent that Pravan will provide you the specific services in Pravan facilities in Puerto Rico (“Services”) herein described:
- SERVICES INCLUDED IN THE MEMBERSHIP FEE
|DESCRIPTION OF SERVICE||COMMENTS|
Comprehensive Initial Evaluation with Physician
|Annual in-depth physical examination and wellness evaluation (“Wellness Evaluation”). As part of the Wellness Evaluation, the Physician will order a panel of laboratory tests, review any relevant medical history and then recommend a personalized health, exercise, and dietary health plan for you to follow. As used in this Agreement, the term “Wellness Evaluation” means a physical examination and wellness evaluation provided to you not in connection with any illness or injury.|
|11 Visits with Physician for Follow Ups or New Issues||Additional appointments for follow ups relating to any prior visit or new issues (in-person or through telemedicine). Women may have the option to use 1 of their 11 additional visits for an annual exam with our gynecologist, if service is available.|
|Unlimited Nutritionist Consults||An initial appointment followed by additional appointments (in-person or through telemedicine).|
|Care Coordination||Initial appointment coordination for external medical services.|
|Vitals||Height, weight, body temperature, blood pressure, heart rate and oxygen saturation.|
|Electrocardiogram||Electrical activity of the heart.|
|Spirometry Test||Lung function capacity test.|
|Bioelectrical Impedance Analysis||Body composition analysis.|
|Physical Exam||Examination of the bodily functions and condition of an individual.|
|Referral to Initial Lab Work||Labs are performed through a third party laboratory that has no contract or professional association with Pravan.|
|Supplement Recommendations||Recommendations for any vitamin or mineral deficiencies or for health optimization|
|Access to Medical Team through HIPAA Compliant App
||Access to Medical Team for telemedicine, care coordination, information and appointment requests
|Health Questionnaire||Questionnaire to be completed in app in preparation for initial visit
- PRAVAN FEE-FOR-SERVICE: ADDITIONAL AVAILABLE SERVICES
Please refer to website (https://pravanhealth.com/pravan/services/) for updated and
current additional wellness services and pricing.
|Urgent Care Services – available for members and non-members (up to 5 family and/or friends). https://pravanhealth.com/pravan/services/#urgent_care|
|Vitamin and Minerals IV Drips|
|Additional Primary Care Physician Visits|
|Additional Gynecological Visits|
|Medical Cannabis Evaluation|
|Additional EKGs, Spirometry and Bioelectrical Impedance Analysis|
Membership Fee and Payment
In exchange for the Services provided for in this Agreement, You agree to pay an annual Membership Fee of two thousand three hundred dollars ($2,300.00), less any special discount (if applicable) for a Membership (Membership Fee), which includes all of the Services detailed in Exhibit I.A., as provided by Pravan physicians or practitioners and as applicable. Membership Fees are not transferable.
The annual Membership Fee covers a period of one (1) calendar year starting on the date your Membership was activated. The Fees are subject to change in subsequent years. Members will be notified upon renewal of the annual membership of any fee increases and may elect to not renew without penalty. Your initial payment must be paid prior to your first visit.
The Membership Fee may be subject to any applicable sale or value added taxes which would be charged in addition to the Membership Fee.
Pravan may offer Additional Available Services to Member, as determined by Pravan Physician, for additional fees (“Additional Fees”) as detailed in Exhibit I.B. Member hereby authorizes Pravan to charge any Additional Fees to the credit card established herein as the payment method established in this Agreement by Member. In the event that You cancel your credit card, or the same is denied for lack of funds, You agree to reimburse Pravan for any and all fees and costs incurred with processing and/or reprocessing any Additional Fees that were unsuccessfully charged to your credit card.
Amendment to Agreement or Services Modification
Pravan may, at its sole discretion, modify, add, discontinue, and/or incorporate new or existing services and offerings to the Services covered under the Membership Fee (“Service Modification”). Any Service Modification will not be cause for termination or otherwise modify any Membership Fees (as hereinafter defined) payable under this Agreement, unless it is a discontinue of a contracted service in which case the Member may request termination of this Agreement and any reimbursement shall be determined as established in Section 7 of this Agreement.
Health Insurance Policy
Pravan does not bill or request reimbursement from Payors or health insurance carriers.
Certain services offered by Pravan may be covered by Your health insurance policy, nonetheless, You agree to be responsible for the payment of the Membership Fee and any Additional Fees, and agree not to bill or request reimbursement from health insurance carriers or any Payor for any covered Services.
Any Member who obtains a Membership under this Agreement 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, nor any services not directly provided by Pravan, or the Physicians at Pravan. As such, Pravan strongly advises You to obtain or keep in full force such health insurance policy(ies) or plans that will cover You for general and specialized healthcare costs. Pravan services are different from the covered services you may have with your insurance plan.
However, if any Member is referred to a Third Party Specialist (who is not under an employment agreement or independent contractor agreement with Pravan), then the Member will be responsible for any payment that is due to such Third Party Specialist for their medical services. The Membership Fee will not include any payment to said Third Party Specialist. Member will be free to use any health insurance, Medicare, or Medicaid coverage that they may have to pay the fees of said Third Party Specialist.
Pravan is not a Medicare or Medicaid provider and shall not bill Medicare for its Pravan Physician services.
Pravan’s Physician Tania Rivera, MD has been contracted as an independent contractor for the provision of Services to Pravan Members, and has Opted out of Medicare since May 2019. Medicare Opt out period for providers is two years and may be renewed automatically. Providers who have Opted out of Medicare shall ensure they have a private contract with Medicare Beneficiaries.
Member acknowledges and understands that Medicare payment will not be made to You for items or services furnished by Pravan physician. If Pravan physician had not opted out of Medicare and no private contract were in place, Medicare would have covered the Services and You would have not been responsible for their payment.
Certain services provided by Pravan may be covered by Medicare, but You agree to pay for Services offered by Pravan through the Membership Fee or as an Additional Fee. Member agrees to be responsible for said payments and not to bill Medicare or any health insurance for said Services. Member agrees to refuse to bill or request reimbursement from any Payor for the Services provided by Pravan.
Since Pravan is not a Medicare provider nor bills for its services, all provided services are either paid for entirely by the Membership Fee or Additional Fees. If You are a recipient of Medicare or Medicaid, then a release as set forth in Exhibit IV (“Medicare Opt Out Agreement”) must be completed as part of the Agreement.
Member agrees to enter into this Private Contract with the knowledge that all Medicare covered services to be provided by opted out physicians could be rendered by physicians not opted out and paid by Medicare. Additionally, that beneficiary is not compelled to enter into private contracts that apply to Medicare covered services by non opted out physician.
Member accepts full responsibility for payment of all charges for the furnished Services. Medicare limits do not apply to what the physician may charge for items or services furnished. You agree not to bill, or attempt to bill or seek reimbursement from Medicare or Medicaid or any Payor for any such Services. Upon any renewal of the Membership, an updated and executed Medicare/Medicaid Exhibit must be submitted to Pravan.
The Term of this Agreement for each Member is for one (1) year from the Effective Date, which is the date you acquire your Membership, subject to the payment of the applicable fees set forth in this Agreement. The Membership and this Agreement will automatically renew for a one (1) year term upon your payment of the Membership Fee. You may cancel the Membership and this Agreement at any time with a 30 day written notice, or You may request that the Agreement run until the end of the current Term and expire upon the anniversary date.
Right to Cancellation
You may cancel this agreement within three (3) days from the date of signing this agreement (exclusive of holidays and weekends) by delivering a written notice of cancellation to Pravan Health, LLC, by email to firstname.lastname@example.org. If you deliver a timely written notice of cancellation, a refund of all monies paid under this agreement shall be issued within thirty (30) days after receipt of such notice of cancellation.
Termination by Member. You may terminate this Agreement at any time with or without cause with a 30 day written notice. You will not be entitled to a refund for any Membership Fee or Additional Fees already paid to Pravan for the Term.
Termination because of Member’s Relocation. Should a Member relocate its residence outside of Puerto Rico, the Membership may be terminated by Member with a 30 day written notice.
Termination with cause. Pravan realizes that dismissing a Member should be an act of last resort, and will take all reasonable measures to avoid terminating a relationship with a Member. Grounds for termination may include, but are not limited to a Member’s:
- Failure to pay any applicable fees or costs
- Bringing forth any claim or legal action, regarding the medical services provided, against Pravan or any of its employees or health staff
- Disparaging public statements made in relation to Pravan
- Non-compliance with the treatment plan
- Repeated missing or skipping of appointments
- Rude, inappropriate or abusive behavior to Physician or other Pravan staff
- Being disruptive, including the use of alcohol/drugs in the clinic
- Drug-seeking behavior
In the case of a Pravan Termination with cause, Pravan will notify the Member in writing of the termination date of this Agreement. Though the membership will be terminated upon notification, Pravan will comply with its Transition of Care Policy, as described in Section 8 of this Agreement.
In the case of a Pravan Termination for cause or breach of this Agreement, any remaining full, unused, calendar months of Membership Fee (as defined below) will not be refundable.
Termination without cause. Pravan may terminate this Agreement at any time without cause with a 30 day written notice. In the case of a Pravan Termination without cause, Pravan will notify the Member in writing of the termination date of this Agreement. Though the membership will be terminated upon notification, Pravan will comply with its Transition of Care Policy, as described in Section 8 of this Agreement.
For terminations without cause or for reason of Member’s relocation, the reimbursement of the Membership Fee shall be processed using the following formula:
Total membership fee paid less $500 (cost of Annual Medical Evaluation) less $350 (Administrative Fee) less $150 times the total number of Full Months of Membership Used.
Total membership fee paid
– ($150) (total number of full months Membership used)
= Total amount to be reimbursed to Member
Any reimbursement will be paid within thirty (30) days of the original request in writing with proof of new residence.
Transition of Care to Other Providers Upon Termination
Transition of care may occur at Member’s request or as a result of Member’s dismissal by Pravan. In either instance Pravan will follow a proper transition of care process to ensure Member’s health and privacy are managed effectively. Pravan or the Member’s Physician will provide recommendations for transfer of care. Upon proper Member authorization, Pravan will transfer medical records to the Member’s new Physician and will be available for case discussion.
Communication of Health Information
Members may communicate with Pravan through electronic means, as well as through telephone calls and in-person visits. As part of the Services, Pravan may, at the Member’s request or at the advice of Pravan Physician, send medical records, laboratory results, prescriptions and other medical information through mail, facsimile transmission or electronic mail to third parties in order to provide the Services. Likewise, Members may send Pravan medical records and other such information through electronic, physical or facsimile means. This information may contain “protected health information” (PHI) (as that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulations), and a Members decision to either receive or send such protected health information to Pravan is a clear release and waiver of any claim under HIPAA against Pravan. You expressly authorize the unsecured transmission of your PHI from Pravan to other providers for treatment purposes. It is the Physician’s obligation to ensure confidentiality with respect to correspondence using such means of communication.
Informed Consent for Telemedicine Services
Pravan Members may be able to consult with providers or specialists admitted to exercise telemedicine as provided by Law 168-2018, known as “Ley para el uso de la Telemedicina en Puerto Rico”. By the execution of this agreement Member consents and understands the following, regarding Telemedicine Services:
The healthcare professionals at Pravan have explained to me the following with regard to the telemedicine consultation:
- The video conferencing technology that will be used will not be and is not the same as a direct patient/health care provider visit; and
- The physician that will be taking the consultation will not be in the same exam room, hospital or healthcare facility, and could be located outside of Puerto Rico.
Pravan professionals have explained to me that as in any healthcare consultation there are potential risks associated with this telemedicine technology, including Internet interruptions, unauthorized access or disclosures and other troubleshooting issues, as well as situations created by violations of security and privacy rules.
My provider of healthcare services also advised me of my right to revoke this consent to telemedicine consultations at any time.
I have the right to request that sensitive information about my identity or health condition be omitted. I can request that only the health personnel needed to be in the examination room are present during any video conference consultation, so that I can limit what is disclosed in such consultation. I understand that my healthcare provider or I can discontinue the video conference consult/visit if ever I feel uncomfortable.
I understand that there will be no physical tests conducted by medical or nursing staff during a telemedicine appointment, as I will not be physically present in the clinic.
I have had the alternatives to a telemedicine consultation explained to me, and I choose to participate in a telemedicine consultation being aware of the particular risks associated with a consultation by electronic means of communication and video conference.
After careful consideration of all of the above-mentioned facts, having had the opportunity to ask questions regarding the telemedicine consultation, I have weighed the benefits and any practical alternatives that have been discussed with me in a language in which I understand.
Membership Information Acknowledgement
I agree to provide valid contact info (phone, address and email) and inform of any changes, download Pravan’s communication app, complete initial medical questionnaire and come to the initial medical evaluation. Patient acknowledges that no prescriptions will be dispensed prior to having a medical encounter.
By signing this Agreement, You understand that the credit card You have on file will be charged when you request any fee for service that is out of the membership fee, as described in Exhibit I or payments of non-compliant fees as described in Exhibit II.
General Prescription Policy:
IF A REQUEST FOR A PRESCRIPTION (INCLUDING REFILLS) HAS BEEN MADE, THE PHYSICIAN MUST REVIEW THE MEMBER’S MEDICAL RECORD PRIOR. THEREFORE, YOUR REQUEST MAY NOT BE PROCESSED IMMEDIATELY. IT IS THE POLICY OF PRAVAN TO COMPLETE ALL LEGITIMATE REQUESTS WITHIN 24 BUSINESS HOURS. ALL PRESCRIPTIONS ARE AT THE DISCRETION OF THE PHYSICIANS.
Once the physician has sent the prescription, we will notify the Member that it has been sent to their preferred pharmacy or is ready for pickup (a physical prescription is required by law for controlled substances). If a patient has not been seen in this office during the preceding 3 months, no prescriptions will be “called in” to the pharmacy without re-assessment of the patient.
Controlled Substances Prescription Policy:
Due to the alarming rate of narcotic pain medication abuse/dependence, it has become necessary for physician practices to closely manage patient use of prescription narcotic pain relievers, such as Vicodin, Vicoprofen, Hydrocodone, Tylenol #3 w/ codeine, Percocet, Percodan, Lorcet, Lortab, Morphine and Opioid products.
The Controlled Substances Prescription Policy of Pravan is as follows:
- No narcotic pain relievers and/or other controlled substances will be prescribed at the time of initial consultation. The physician should manage all pain medication until the time that a final treatment plan has been recommended by this office. It is unlikely that a final treatment plan can be recommended at the initial visit since most patients will not have had all of the necessary diagnostic tests required to form an accurate diagnosis (i.e. MRI, x-rays, EMG, CT scan, etc.).
- Once the final diagnosis has been made, this office will recommend a treatment plan that may or may not include the short-term use of narcotic pain medication and/or other controlled substances.
- Under no circumstances will narcotic pain medication be prescribed beyond a 90-day period. If narcotic pain management is required beyond 90 days, then a referral to a Chronic Pain Specialist will be made.
- In the event of suspected narcotic or other controlled substances abuse, further prescriptions of these medications will not be made.
- In the event of documented narcotic abuse, further prescriptions will not be made, and the patient may be discharged from care.
- In the event of suspected narcotic dependence, a referral to a Dependency Treatment Specialist can be made, at the member’s request.
As a member of Pravan, I have read and understand Pravan’s Prescription Policy.
Members, through their Membership or as Additional Available Services have access to appointments with Pravan Physicians. Members must request their appointments ahead of time and must ensure that they are on time for their appointments. Should You need to cancel or reschedule an appointment You must contact Pravan no later than 24 hours prior to Your scheduled appointment. Cancellations with less than 24 hours notification will incur the payment of fees as established in Exhibit II.
Appointment Non Compliance & Applicable Fees
In order to ensure that we have adequate resources to properly care for all of our members we have established the following policies. Please thoroughly review this important information.
|Visit Type||Applicable Fees (to be charged to the credit card on file)|
|>10 Minute Late Arrival to Pravan Health||No Show, No Notification||Notification
<24 Hours of Appointment
>24 Hours of Appointment
|Initial/Annual Evaluation Visit (1 Included in Membership)||Subject to same fees as “No Show, No Notification” unless
otherwise determined by Pravan Team that appointment can start late without affecting other appointments.
|New Issues & Follow Up Visits with MD (11 Included in Membership)||$50||$50||No fee.|
|Nutritionist Appointments: (Unlimited Visits Included in Membership)||$25||$25||No fee.|
**Made to order specifically for you. IVs are not refundable or returnable once ordered for You.
|100% of IVPrice||100% of IVPrice||100% of IV Price|
Follow ups/New Issues
|All Other Services & Appointments (Fee For Service)||100% of service amount||100% of service amount||No fee.|
**In the case of an emergency, the case will be evaluated by Pravan to determine if the above policy should apply.
By signing this Agreement, You understand that the credit card You have on file will be charged
at the time of the scheduled appointment according to the above Policy.
Policies and Procedures.
Member agrees to comply with Pravan Policies and Procedures described in this document and attachments in Exhibits I – IV.
Limit of Authority; Release of Liability.
As a Member under this Agreement, I understand that Pravan does not have any control over, or the right to control, the professional judgment of, treatment by, or medical actions of contracted Physicians with respect to professional services rendered by Physician as it relates to medical/patient care decisions. I also understand that the Physician shall retain all responsibility for any and all medical care provided to me. I further acknowledge and agree that Pravan does not furnish medical services to me as a Member, either directly or indirectly, and that the Physician is solely responsible for the quality of care and medical decision-making with respect to all medical services, rendered to Members.
As such, in consideration of my participation in Pravan services, I for myself, hereby release Pravan, its employees, spouses, relatives, heirs, assigns, agents, officers, directors, and shareholders, from any and all claims, demands or causes of action arising from my participation under this Agreement.
I fully understand that I may suffer injury as a result of Physician’s professional judgment and medical decision-making, and I hereby release Pravan from any and all liability now or in the future, including but not limited to any medical malpractice liability, and including, but not limited to, medical expenses, lost wages, pain and suffering, that may occur, however caused, whether occurring during or after my participation in Pravan services.
The provisions of this Section shall be deemed continuing and shall survive any termination or expiration of this Agreement.
This Agreement is exclusive to Members. Members cannot assign this Agreement, its benefits, Services, responsibilities or terms to any other person or entity, without the express written consent of Pravan. Pravan may, at its sole discretion, decide not to accept any assignment of this Agreement to any third party that Member may wish to assign the Agreement to.
The obligations of Pravan are subject to force majeure and Pravan shall not be in default under this Agreement if any failure or delay in performance is caused by work stoppage or other labor problems; accident; acts of God; fire; flood; adverse weather conditions; material or facility shortages or unavailability not due to any fault of Pravan not resulting from its failure to timely place orders therefore; lack of transportation; condemnation or exercise of rights of eminent domain; or civil disorder; or any other cause beyond the reasonable control of Pravan. Once the Force Majeure Event has passed, Pravan will take all commercially reasonable steps to provide the Services under this Agreement.
This Agreement constitutes the entire and exclusive statement of the agreement between the parties with respect to its subject matter and there are no oral or written representations, understandings, or agreements relating to this Agreement which are not fully expressed herein. The parties agree that any other terms or conditions shall not be incorporated herein or be binding unless expressly agreed upon in writing by authorized representatives of the parties. By clicking on the “I Agree” button below, Member hereby provide express consent to this Agreement. Member shall physically sign a copy of this Agreement upon first visit to Pravan as a Member.
Relationship of Parties
You and the Physician intend and agree that the Physician, in performing their duties under this Agreement, is an independent contractor, and Physician shall have exclusive control of their work and the manner in which it is performed.
Amendments to the Agreement
Pravan may, at its sole discretion, amend or modify this Agreement. However, any amendment or modification to this Agreement will only enter into effect after the current Term expires and Membership renews.
Any communication required or permitted to be sent to the other party under this Agreement shall be in writing sent via our communication app, email, certified mail, return receipt requested, to the address given to Pravan staff when activating your membership, or by hand delivery or delivery by FedEx or similar delivery service. Any changes in address shall be communicated to Pravan by Member.
No waiver of any provision of this Agreement, or of a breach hereof, shall be effective unless it is in writing, signed by the Party waiving the provision or the breach hereof. No waiver of a breach of this Agreement (whether express or implied) shall constitute a waiver of any subsequent breach hereof.
Interpretation; Headings; Severability
The headings used in this Agreement are for convenience only and shall have no significance in the interpretation of this Agreement. All provisions of this Agreement are severable, and the unenforceability or invalidity of any of the provisions of this Agreement shall not affect the validity or enforceability of the remaining provisions of this Agreement. In other words, if a court of law were to find that a specific clause of this Agreement is not valid, that determination would not render the entire Agreement as invalid. Those clauses that were not determined to be invalid by a court of law would remain in effect and Member would continue to be bound by them.
This Agreement is governed by the laws of the Commonwealth of Puerto Rico without giving effect to choice of law principles. Without limiting any other provision of this Agreement, which by their terms or as to which such survival is implicit shall survive the termination or expiration of this Agreement and termination of Member’s membership and shall remain in full force and effect thereafter.
MEDICARE OPT OUT AGREEMENT
-To be completed ONLY by Medicare beneficiaries-
This Medicare Opt-Out Agreement (“Opt-Out Agreement”) is between Pravan Health, LLC, and Tania Rivera, M.D. (collectively, the “Physician”), and _____________________ (the “Member”), and is a Medicare beneficiary seeking services covered under Medicare.
- Physician agrees to provide the medical services described in the Concierge Services Member Agreement (the “Services”) to the Member. In exchange for these Services, the Member agrees to make payment to Physician pursuant to the Membership Fee attached to the Concierge Services Member Agreement.
- Member agrees, understands, and expressly acknowledges the following:
- Member accepts full responsibility to make payment in full for the Services.
- Member acknowledges that neither Medicare’s fee limitations nor any other Medicare reimbursement regulations apply to charges for the Services.
- Member agrees not to submit a claim (or to request that Physician submit a claim) to the Medicare program with respect to the Services, even if covered by Medicare Part B.
- Member acknowledges that Physician will not submit a Medicare claim for the Services and that no Medicare reimbursement will be provided.
- Member 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 were no private contract and a proper Medicare claim had been submitted.
- Member acknowledges that he has a right, as a Medicare beneficiary, to obtain Medicare covered items and services from physicians and practitioners who have not opted-out of Medicare, and that he 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.
- Member acknowledges that Medi-Gap plans will not provide payment or reimbursement for the Services because payment is not made under the Medicare program, and other supplemental insurance plans may likewise deny reimbursement.
- Member is not currently in an emergency or urgent health care situation and recognizes that Pravan does not provide Emergency or Urgent Healthcare and if in an emergency or urgent health care Member will visit an Emergency Room.
- Member acknowledges that a copy of this Opt-Out Agreement has been made available to him before items or services were furnished to him under the terms of the Patient Membership Agreement.
- Member accepts full responsibility to make payment in full for the Services.
- This Opt-Out Agreement is limited to the concierge patient membership arrangement between Physician and Member and is not intended to obligate either party to a specific course or duration of treatment.
- The Physician has informed the Member that Physician has opted out of the Medicare program effective on April 2019.
- The parties agree that this Opt-Out Agreement shall be fully binding to their heirs, successors, and assigns.
NOTICE OF PRIVACY PRACTICES
Your Information, Your Rights, Our Responsibilities
Pravan Health, LLC
Address: Cond. La Ciudadela, 1511 Juan Ponce de Leon Ave. Ste. 3 S.J. P.R. 00909
Privacy Officer: Ruth González
Telephone Number: 787-339-2639
Email Address: email@example.com
Effective Date: 4/25/19
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
WHO WILL FOLLOW THIS NOTICE
- This Notice of Privacy Practices (the “Notice”) describes Pravan Health, LLC, (the “Company”/PRAVAN) practices and those of Company employees, staff, volunteers, and other personnel who are involved in your care. The Company and these individuals will follow the terms of this Notice, and may use or disclose medical information about you to carry out treatment, payment or health care operations, or for other purposes as permitted or required by law. This Notice describes your rights to access and control medical information about you, including information that may identify you and that relates to your past, present, or future physical, medical, or mental condition and medical care and related health care services. Your personal Physician may have other policies that he or she follows if he or she sees you outside of the Company and may use his or her own Notice of Privacy Practices.
THE COMPANY’S PLEDGE REGARDING MEDICAL INFORMATION
- PRAVAN understands that medical information about you and your health is personal. PRAVAN is committed to protecting medical information about you. Health information that the Company receives and/or creates about you, personally, relating to your past, present, or future health, treatment, or payment for health care services, is “protected health information” under the federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164. In order to provide you with quality care and to comply with certain state and federal legal requirements, PRAVAN creates a record of the services you receive at our location. This Notice applies to all of the records of your care generated by PRAVAN. This Notice will tell you about the ways in which the Company may use and disclose medical information about you. It also describes your rights and certain obligations PRAVAN has regarding the use and disclosure of medical information. The Company is required by law to: (1) Make sure that medical information that identifies you is kept private; (2) Give you this Notice of its legal duties and privacy practices concerning medical information about you; (3) Follow the terms of the Notice that are currently in effect, and (4) Notify you in case there is an unauthorized use or disclosure of your unsecured medical information.
YOUR RIGHTS: When it comes to your health information, you have certain rights. This section explains your rights and some of your responsibilities to help you.
- Right to Inspect and Copy:
- You can ask to see or obtain an electronic or paper copy of your medical record and other health information we have about you. We will provide a copy or a summary of your health information, usually within 5 days of your request. We may charge a reasonable, cost-based fee.
- Amendment to Your Information:
- If you feel that medical information about you is incorrect or incomplete, you may ask PRAVAN to amend the information. We will answer said request in the affirmative or negative in writing within 60 days of your request.
- Right to an Accounting of Disclosures:
- You have the right to receive a list of certain disclosures we may have made of your medical information.
- Right to Request Restrictions:
- You have the right to request a restriction or limitation on the medical information that PRAVAN uses or discloses about you for treatment, payment or health care operations, and to request a limit on the medical information that the Company may disclose to family members or friends involved in your care.
- Request Confidential Communications
- You have the right to request that PRAVAN communicates with you about your appointments or other matters related to your treatment in a specific way or at a specific location. We will say “yes” to all reasonable requests.
- Receive a Copy
- You have the right to obtain a copy of this notice.
- Right to File a Complaint:
- You can complain if you feel we have violated your rights by contacting us using the information provided.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
HOW THE COMPANY MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that PRAVAN may use or disclose protected medical information. For each category of uses and disclosures, the Company will explain what is meant and may give some examples. Not every use or disclosure in a category will be listed. However, all of the ways PRAVAN is permitted to use and disclose information will fall within one of the categories. Some information such as psychotherapy notes, certain drug and alcohol information, HIV, or mental health information is entitled to special restrictions.
- For Research:
- PRAVAN may disclose medical information about you to researchers when the information does not directly identify you as the source of the information or when a waiver has been issued by an institutional review board or a privacy board that has reviewed the research proposal and protocols for compliance with standards to ensure the privacy of your health information.
- For Health Care Operations:
- PRAVAN may use and disclose medical information about you to carry out activities that are necessary for Company operations. These uses or disclosures are made for quality of care, compliance activities, administrative purposes, contractual obligations, grievances or lawsuits. For example, PRAVAN may use medical information to review treatment and services provided at the Company or to evaluate the performance of its staff and contractors in caring for you.
- To Individuals or Family Members Involved in Your Health Care:
- Unless you object, PRAVAN may disclose medical information about you to a member of your family, a relative, a close friend or any other person that you identify who is involved in your care. The Company may also tell your family or friends, personal representative, or any other person who is responsible for your care, of your location, general condition or death, unless you object. Please inform us of the person you authorize to disclose medical information.
- PRAVAN may disclose medical information about you to a public or private entity assisting in disaster relief so that your family can be notified about your condition, status, or location. You may object to this disclosure with a written request. However, if you are not available or are unable to agree or object, or in some emergency circumstances, PRAVAN will use its professional judgment to decide whether this disclosure is in your best interest.
- As Required by Law:
- PRAVAN will disclose your health information when required to do so by federal, state or local law.
- Workers Compensation:
- PRAVAN may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
- For Public Health Activities:
- PRAVAN may disclose medical information about you for public health activities. These purposes generally include the following: (1) To prevent or control disease, injury, or disability; (2) To report deaths; (3) To report abuse or neglect of children, elders and dependent adults; (4) To report reactions to medications or problems with products; (5) To notify people of recalls of products they may be using; and (6) To notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease or condition.
- For Health Oversight Activities
- PRAVAN may disclose medical information about you to a health oversight agency for activities authorized by law.
- For Lawsuits and Disputes:
- PRAVAN may disclose medical information about you in response to a court or administrative order, subpoena, discovery request, or other lawful process.
- Disclosure to Law Enforcement:
- If asked to do so by law enforcement and as authorized or required by law, PRAVAN may release medical information: (1) To identify or locate a suspect, fugitive, material witness, or missing person; (2) About a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; (3) About a death suspected to be the result of criminal conduct; (4) About criminal conduct at the Company; and (5) In case of a medical emergency, to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
- PRAVAN may release medical information about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. PRAVAN may also release medical information about you to funeral directors. PRAVAN may also release information to any individual known to PRAVAN as a family member, close personal friend of the family, or any other person identified, who was involved in your care or the payment for your care prior to your death, unless you indicate otherwise. Your medical information may be used or disclosed to others without your authorization after fifty (50) years from the date of your death.
- For Specialized Government Functions:
- PRAVAN may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities.
- Information About Inmates/Individuals in Custody:
- If you are an inmate or under the custody of a law enforcement official, PRAVAN may release medical information about you to the correctional institution or law enforcement official responsible for you as authorized or required by law.
- Disclosure for Threats to Health and Safety:
- In certain circumstances, PRAVAN may be required to disclose medical information to avert a serious threat to your health and safety or the health and safety of another person as required by law enforcement. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.
- Marketing Purposes, Sale of Your Information:
- The Company will not release or sell your medical information for marketing purposes without an express written authorization from you.
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.com
CHANGES TO THIS NOTICE
- PRAVAN reserves the right to change the terms of this Notice at any time. PRAVAN reserves the right to make the revised or changed notice effective for medical information PRAVAN already has about you as well as any information PRAVAN receives in the future. The Company will post a copy of the current Notice. The Notice will contain an effective date.
QUESTIONS AND COMPLAINTS
- If you have any questions or believe that your privacy rights have been violated, you may contact PRAVAN HIPAA Privacy Officer in person, by email or mail a written summary of your concern to the contact information provided
- You will not be penalized or retaliated against for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
- Other uses and disclosures of medical information not covered by this Notice or the laws that apply to use will be made only with your written permission. If you provide PRAVAN permission to use or disclose medical information about you, you may revoke that permission in writing at any time. If you revoke your permission PRAVAN will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if PRAVAN has already acted in reliance on your permission. You understand that PRAVAN is unable to take back any disclosure PRAVAN has already made with your permission and that the Company is required to retain its records of the care that the Company provided to you.