Aesthetic Clinic Services in Orlando, FL

You should always be proud of your body and how you look. However, certain features, especially those because of aging and weight, can negatively affect your image of yourself and your self-confidence. Boutiq offers convenient and safe aesthetic clinic services in Orlando, FL, so that you can easily achieve the more youthful appearance and glow that you are looking for.

Our Range of Aesthetic Services

The professional practitioners at Boutiq recognize that everyone has different needs, so we offer a range of aesthetic services to fit those needs.

Dermal Fillers Restylane®, Juvederm®, and Revanesse®

These treatments feature several types of hyaluronic acid options for multiple facial improvements. With dermal fillers, we can erase smile lines, plump lips, contour, soften the skin, and add volume to the skin as well. We will simply instill the filler product into the problematic areas to achieve your desired result. There is little to no downtime, and you will see instant results. This treatment lasts approximately 12 months.

Botox® and Dysport®

These two treatments involve essentially painless tiny injections that relax wrinkles and allow for a smoother, rejuvenated skin appearance. This treatment requires no downtime, and you will start noticing results within 3–14 days.

Typical treatment areas are between the eyes, on the forehead, and at crow's-feet; however, other areas of the face, neck, and décolletage may be treated. Botox® and Dysport® are also excellent treatments for wrinkle prevention.

Aquagold® Fine Touch™ Microneedling

This luxury 24-carat gold plated medical microneedling device delivers a specialized blend of skin boosters, favored by Hollywood elites, to achieve maximum results. This revolutionary micro-infusion delivery mechanism is patented and FDA approved. Benefits include:

Rejuvenation may be provided on the face, neck, décolletage, and hands. We will customize your treatment utilizing medical-grade vitamins, growth factors, peptides, 100% pure HA, antioxidants, skin brighteners, and even Botox (often referred to as baby Botox). This Super Facial requires no downtime.

Our Company and Experience

At Boutiq, our goal is to help you live a healthier, happier life. In addition to high-quality care and accessibility, one of our main priorities is affordability; many of our staff worked in traditional healthcare previously, and they all grew tired of seeing patients walk away because a treatment was too expensive. Our primary focus is not on prices or insurance companies — our focus is on the health and wellness of our patients. We will help you look and feel your best!

Contact us today at (407) 777-2449 to book your appointment.

Please Select a Plan

BOUTIQ MEDICAL CLINIC, LLC

PATIENT MEMBERSHIP AGREEMENT


This Membership Agreement is a contract for medical services to be provided by Boutiq Medical Clinic, LLC, and is effective as of the last date entered below.


Boutiq Medical Clinic, LLC (“Practice”), is a direct care practice, serving ages 7 and older, that currently aims to supplant the traditional insurance-based care model with conventional and innovative care delivery methods and services for a membership/subscription fee.


The Practice provides a range of family, pediatric, and other health services to its patients.


The Practice, is independently owned and operated, and employs different types of medical providers for the purpose of treating its patients.


The Practice is located at 1430 N. Mills avenue, Suite 120, Orlando, Florida 32803, and all office-based services are provided at that location.


The Practice’s regular hours are as follows:


Monday through Friday- 8am to 6pm

Saturday- 9am to 2pm

Sunday- Closed


At the Practice’s discretion, limited appointments may be made available on days and at times when it would normally be closed. Regular hours may vary.


During hours when the main office is closed, or during the business day, and when appropriate, the Practice may elect to provide virtual/telemedicine services to its patients.  No guarantee is made that these services will in fact be offered.


The terms “you” or “the Patient” refers to the patient whose signature appears on the signature page of this Agreement.  If the signature page or any schedule attached to this Agreement indicates that the term “you” or “the Patient” is intended to mean a couple or family (parents and children), then any references in this Agreement will mean each member of your family.


By signing this Agreement you are stating that you want to receive, in exchange for a fee, certain medical and non-medical services (collectively the "Services") from the Practice as part of your membership in the Practice.


The purpose of this Agreement is to define how and what Services will be furnished to you by the Practice.


ARTICLE 1 - PAYMENT


1.1 In exchange for the services provided for in this Agreement, you agree to pay the Practice the fees for the services you request as listed on the Fee List in Schedule B.


ARTICLE 2 - MEDICAL SERVICES


2.1 The Practice will provide you with the Services listed on the Menu of Services in Schedule C.  In this Agreement, the term Medical Services means the services that the Practice’s providers personally provide, as well as those services that staff members are permitted to provide at the direction or under supervision pursuant to the laws of the State of Florida.  Generally, Medical Services include health promotion, disease prevention, diagnosis, care, and treatment of patients during all stages of life.  Medical Services specifically include and exclude those items listed in Schedule C.


2.2 Alternate Provider.  Member understands that the Practice’s primary provider may be unavailable to provide services at times due to patient care obligations, illness, injury, vacation or other similar obligations.  During those particular times, the Practice will reasonably attempt to make arrangements to ensure another provider is able to assist you with your medical needs, or to be available via remote means of communication (i.e. through telemedicine).  The substitute provider may be, as permitted by law:  a substitute physician; nurse practitioner; registered nurse; physician assistant; or medical assistant.


2.3 Billing to Insurance Companies.  The Practice will provide the full range of services normally provided by a primary care physician in an office, via telemedicine, or in house call settings.  The Practice will not, even if covered by your primary insurance policy, bill those services to the insurance company or accept as payment in full, the reimbursement remitted by the insurer.  The Practice will, at its discretion, provide you with an explanation of the services provided by it so that you can seek reimbursement from your own insurer, if any.  The Practice will not communicate with the insurance company, nor will it change or modify its medical decision-making based on what your insurance company may, or may not, reimburse.



ARTICLE 3 - NON-MEDICAL SERVICES


3.1 24/7 Access; After Hours Care.  As a member of the Practice you will have direct access to the Practice’s providers via the patient portal (registration required by you) on a twenty-four hour per day, seven day per week basis for non-urgent matters. The Providers will respond as time permits. During the Provider's absence for vacations, continuing medical education, illness, emergencies, or normal days off, the Practice will be unavailable.  You acknowledge that the Practice’s providers may, from time to time, not be available at the times referred to above.


If at any time you experience an emergency medical situation that is life threatening or of a serious nature, you should NOT call or message the Practice but instead you should CALL 911 IMMEDIATELY.


3.2 Fax and E-Mail Access. You will be given the Practice’s fax number and e-mail address to which you can send non-urgent messages.  These communications will be handled by a staff member of the Practice in a timely manner, including a reasonably prompt response to you by the Provider or by the staff member.  E-mails will typically receive a response within twenty-four (24) hours.  If you do not receive a timely response, you should call the Practice directly or try an alternate means of communication.  In order to receive a response by e-mail or text message, you will be required to sign the Practice’s form outlining its policy on unsecured electronic communications. Again, all medical emergencies should be directed to 911, not the Practice.


3.3 Same Day/Next Day Appointments.  If you call or e-mail the Practice prior to noon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort will be made to schedule an appointment on the same day.  If you call or e-mail the Practice after noon on a normal office day to schedule an appointment, every reasonable effort will be made to schedule an appointment on the following day.  In any event, however, the Practice will make every reasonable effort to schedule an appointment for you on the same day that the request is made.  The Practice may satisfy its obligation to provide a prompt appointment under this section by scheduling a virtual/telemedicine visit with one of its providers if an in-office appointment is unavailable. The best way to schedule your appointment is via the website/patient portal or App. You may also walk in.


3.4 Hospital Visits.  Treatment in a hospital is not provided.  


3.5 Vaccines.  The Practice may, at your request, administer routine vaccinations when available.  The office visit for vaccine administration is covered by this Agreement, and is included in your membership fee.  However, the cost of the vaccine is not included.  Exact pricing for vaccinations is available upon request and will vary from time to time as suppliers adjust their pricing.



ARTICLE 4 – TERM AND TERMINATION


4.1 Term.  This Agreement will commence as of the date the last party signs it and will extend for one (1) year from that date.  Either party may terminate this Agreement at any time upon thirty (30) days written notice, however, no portion of the Enrollment Fee will be refundable.  However, if the Practice terminates this Agreement or stops providing direct care services, any monthly membership fees you paid in advance will be refunded to you as required by Florida law.


4.2 Renewal  This Agreement will automatically renew for additional one (1) year periods if neither you nor the Practice gives written notice that it does not want this Agreement to renew at least thirty (30) days prior to the current expiration date.  The Practice reserves the right to amend this Agreement on an annual basis to reflect certain operational changes and costs of operation.  The Practice will provide written notice of any change in terms as soon as reasonably practicable prior to the expiration date.  If Practice provides less than thirty (30) days’ notice of proposed changes, your obligation to provide thirty (30) days’ notice of intent not to renew is waived.  Should Practice provide appropriate notice of changes and you do not give timely notice that you do not want to renew, the Agreement will renew on the modified terms provided by the Practice.


4.2 The Practice may terminate your membership if you, or any member of your family, behave in an abusive or improper manner, or, if you fail to pay any fee or charge due for services.  In the event that the Practice exercises its right to terminate this Agreement for abusive or improper behavior or for failure to pay any fees or charges, the Practice is under no obligation to refund any portion of the Enrollment Fee or any Monthly Membership Fee, except those monthly membership fees you may have paid in advance.





ARTICLE 5 – NON-PARTICIPATION IN INSURANCE AND MEDICARE


5.1 Notice of Non-Participation Status.  As a direct care practice, the Practice does not participate in Medicare, Medicaid, Tricare, or any other government or private insurance plan.  As stated above, the Practice will not bill any services to an insurance company of any kind.


You acknowledge that the Practice does not participate in your health insurance, HMO, PPO, or POS plan or panel in any way and/or has OPTED OUT OF MEDICARE or is otherwise a NON-PARTICIPATING PROVIDER.  Neither the Practice nor its providers make any representation whatsoever that any fee for services provided by the Practice is covered by, or reimbursable by, your health insurance or by other third party discount or payment plans in which you or your family may be enrolled.  You will have the full and complete responsibility for any and all charges of the Practice not covered by your membership/subscription fee.  If you are eligible for Medicare, Medicaid, CHIP, or any other federal or state funded health plan, or become eligible during the term of this Agreement, then you agree to sign Schedule D.


5.2 Services Offered Are Not Insurance.  You understand and acknowledge that this Agreement does not provide health insurance coverage, including the minimal essential coverage required by applicable federal or state law.  It provides only the services described herein. It is recommended that health care insurance be obtained to cover medical services not provided for under this Agreement.



ARTICLE 6 – ARBITRATION


6.1 Arbitration of Disputes. In the event of any controversy or claim arising out of this Agreement, you agree that the dispute will be settled by submission to mandatory, confidential, and binding arbitration.  A copy of the Practice’s current arbitration policy is available upon request and incorporated into this section.  If not policy is in place, then arbitration will be before the American Health Lawyers Association’s Alternative Dispute Resolution Service employing its then-current arbitration rules.


ARTICLE 7 – COMMUNICATIONS


7.1 Unsecured Electronic Communication.  You acknowledge that communications with the Practice using fax, e-mail, and text are not guaranteed to be secure or confidential.  As such, you expressly waive the Practice’s obligation to ensure confidentiality with respect to unsolicited fax, e-mail, or text message communication.  


7.2 Al Communications Part of Record.  All communications with the Provider, regardless of form, may become a part of your medical records which may be produced to third parties in accordance with the law.

7.3 Acknowledgement Regarding E-mail Communication.  In authorizing the Practice to communicate with you by e-mail regarding your “protected health information” (PHI) using your e-mail address shown on the attached Schedule A, you acknowledge that:


7.3.1 E-mail is not a secure means for sending or receiving PHI and, in particular, if you send or receive e-mail through your employer’s email system, the employer may have the right to review it;


7.3.2 Although the Practice and the Provider will make reasonable efforts to keep e-mail communications confidential and secure, neither the Practice nor the Provider can assure or guarantee the confidentiality of e-mail communications;


7.3.3 In the discretion of the Provider, e-mail communications may be made a part of your permanent medical record; and


7.3.4 E-mail is not an appropriate means of communication regarding emergency or other time-sensitive issues or inquiries regarding sensitive information.


7.4 Unanswered/Delayed Responses to Communications.  If you do not receive a response to your e-mail message within one business day, you agree to use another means of communication to contact the Practice.  Neither the Practice nor its providers will be liable to you for any loss, cost, injury or expense caused by, or resulting from a delay in responding to you as a result of technical failures, including, but not limited to, (i) technical failures attributable to any internet service provider; (ii) power outages, failure of any electronic messaging software, failure to properly address e-mail messages; (iii) failure of the Practice’s computers or computer network, or faulty telephone or cable data transmission; (iv) any interception of e-mail communications by a third party; or (v) your failure to comply with the guidelines regarding use of e-mail communications in this paragraph.


Urgent, but non-emergency, medical questions or concerns should be communicated by telephone directly to the Practice.  If you are unable to reach the Practice by telephone, you agree to contact 911 immediately.



ARTICLE 8 – INSURANCE OR OTHER MEDICAL COVERAGE


8.1 Not Insurance.  This Agreement is not a substitute for health insurance or other health plan coverage (such as membership in an HMO, PPO, or POS).  This Agreement is not the purchase of insurance and is not enrollment in a health plan.  You agree that the Practice has advised you to purchase or keep in full force your health insurance policy(ies) or plans in order to cover you and your family members for healthcare costs not within the definition of Medical Services under this Agreement (or if this Agreement is terminated) and to prevent gaps in health coverage.


8.2 Referrals.  You understand and agree that from time to time, the Practice may order certain diagnostic/laboratory tests/point of care tests/injections that are not included in your membership or make referrals to a specialist.  The fees associated with those tests and evaluations by other providers are not covered and will not be reimbursed or credited in any way by the Practice.  You are responsible for arranging payment with those other providers directly.



ARTICLE 9 – OTHER TERMS


9.1 Assignability. You may not assign this Agreement or any rights you may have under it.  The Practice may assign this Agreement to an entity that purchases all of its assets or stock, or to another entity following an internal corporate reorganization.


9.2 Notices. All notices, requests, demands and other communications required or permitted under this Agreement must be in writing and delivered to the Practice at the address listed above.


9.3 Severability; Payment.  If for any reason any provision of this Agreement is deemed, by a court, to be legally invalid or unenforceable, the remainder of the Agreement is not affected.  The parties agree to modify the problematic provision to the minimum extent necessary to make it consistent with the law.  If for any reason the entire Agreement is held to be invalid, the Practice is entitled to a reasonable payment for the Services provided to you and your family members.


9.4 Legal Significance.  You acknowledge that this Agreement is a legal document and creates certain rights and responsibilities.  You also acknowledge that you have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.


9.5 Attached Schedules/Amendments. The attached Schedules A through D are incorporated into this Agreement.


9.6 Governing Law.  This Agreement is governed by the laws of the state of Florida.  All disputes not settled by arbitration must be resolved in the state or federal courts in or for Orange County, Florida.


9.7 Venue.  Venue for any arbitration or other legal proceeding lies in Orange County, Florida.  The parties waive any challenge to venue on any and all grounds including forum non conveniens.


9.8 Entire Agreement. This Agreement contains the entire understanding of the parties and supersedes all prior and contemporaneous agreements and understandings, inducements, or conditions, express or implied, oral or written, except as stated in the terms of this Agreement.


9.9 Amendment. This Agreement may not be modified or amended other than in writing and signed by all parties.


******** SIGNATURE PAGE TO FOLLOW ********


SECTION 624.27(4)(h), FLORIDA STATUTES, DISCLOSURE


THIS AGREEMENT IS NOT HEALTH INSURANCE AND THE PRIMARY CARE PROVIDER WILL NOT FILE ANY CLAIMS AGAINST THE PATIENT’S HEALTH INSURANCE POLICY OR PLAN FOR REIMBURSEMENT OF ANY PRIMARY CARE SERVICES COVERED BY THE AGREEMENT. THIS AGREEMENT DOES NOT QUALIFY AS MINIMUM ESSENTIAL COVERAGE TO SATISFY THE INDIVIDUAL SHARED RESPONSIBILITY PROVISION OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT, 26 U.S.C. S. 5000A. THIS AGREEMENT IS NOT WORKERS’ COMPENSATION INSURANCE AND DOES NOT REPLACE AN EMPLOYER’S OBLIGATIONS UNDER CHAPTER 440.


Attachments:

Schedule A:  Membership Enrollment Form

Schedule B:  Fee Schedule

Schedule C:  Menu of Services/Membership Benefits

Schedule D: Medicare Opt-Out Agreement/Member Signature

Thank you! Your submission has been received!
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BOUTIQ MEDICAL CLINIC, LLC

PATIENT MEMBERSHIP AGREEMENT


This Membership Agreement is a contract for medical services to be provided by Boutiq Medical Clinic, LLC, and is effective as of the last date entered below.


Boutiq Medical Clinic, LLC (“Practice”), is a direct care practice, serving ages 7 and older, that currently aims to supplant the traditional insurance-based care model with conventional and innovative care delivery methods and services for a membership/subscription fee.


The Practice provides a range of family, pediatric, and other health services to its patients.


The Practice, is independently owned and operated, and employs different types of medical providers for the purpose of treating its patients.


The Practice is located at 1430 N. Mills avenue, Suite 120, Orlando, Florida 32803, and all office-based services are provided at that location.


The Practice’s regular hours are as follows:


Monday through Friday- 8am to 6pm

Saturday- 9am to 2pm

Sunday- Closed


At the Practice’s discretion, limited appointments may be made available on days and at times when it would normally be closed. Regular hours may vary.


During hours when the main office is closed, or during the business day, and when appropriate, the Practice may elect to provide virtual/telemedicine services to its patients.  No guarantee is made that these services will in fact be offered.


The terms “you” or “the Patient” refers to the patient whose signature appears on the signature page of this Agreement.  If the signature page or any schedule attached to this Agreement indicates that the term “you” or “the Patient” is intended to mean a couple or family (parents and children), then any references in this Agreement will mean each member of your family.


By signing this Agreement you are stating that you want to receive, in exchange for a fee, certain medical and non-medical services (collectively the "Services") from the Practice as part of your membership in the Practice.


The purpose of this Agreement is to define how and what Services will be furnished to you by the Practice.


ARTICLE 1 - PAYMENT


1.1 In exchange for the services provided for in this Agreement, you agree to pay the Practice the fees for the services you request as listed on the Fee List in Schedule B.


ARTICLE 2 - MEDICAL SERVICES


2.1 The Practice will provide you with the Services listed on the Menu of Services in Schedule C.  In this Agreement, the term Medical Services means the services that the Practice’s providers personally provide, as well as those services that staff members are permitted to provide at the direction or under supervision pursuant to the laws of the State of Florida.  Generally, Medical Services include health promotion, disease prevention, diagnosis, care, and treatment of patients during all stages of life.  Medical Services specifically include and exclude those items listed in Schedule C.


2.2 Alternate Provider.  Member understands that the Practice’s primary provider may be unavailable to provide services at times due to patient care obligations, illness, injury, vacation or other similar obligations.  During those particular times, the Practice will reasonably attempt to make arrangements to ensure another provider is able to assist you with your medical needs, or to be available via remote means of communication (i.e. through telemedicine).  The substitute provider may be, as permitted by law:  a substitute physician; nurse practitioner; registered nurse; physician assistant; or medical assistant.


2.3 Billing to Insurance Companies.  The Practice will provide the full range of services normally provided by a primary care physician in an office, via telemedicine, or in house call settings.  The Practice will not, even if covered by your primary insurance policy, bill those services to the insurance company or accept as payment in full, the reimbursement remitted by the insurer.  The Practice will, at its discretion, provide you with an explanation of the services provided by it so that you can seek reimbursement from your own insurer, if any.  The Practice will not communicate with the insurance company, nor will it change or modify its medical decision-making based on what your insurance company may, or may not, reimburse.



ARTICLE 3 - NON-MEDICAL SERVICES


3.1 24/7 Access; After Hours Care.  As a member of the Practice you will have direct access to the Practice’s providers via the patient portal (registration required by you) on a twenty-four hour per day, seven day per week basis for non-urgent matters. The Providers will respond as time permits. During the Provider's absence for vacations, continuing medical education, illness, emergencies, or normal days off, the Practice will be unavailable.  You acknowledge that the Practice’s providers may, from time to time, not be available at the times referred to above.


If at any time you experience an emergency medical situation that is life threatening or of a serious nature, you should NOT call or message the Practice but instead you should CALL 911 IMMEDIATELY.


3.2 Fax and E-Mail Access. You will be given the Practice’s fax number and e-mail address to which you can send non-urgent messages.  These communications will be handled by a staff member of the Practice in a timely manner, including a reasonably prompt response to you by the Provider or by the staff member.  E-mails will typically receive a response within twenty-four (24) hours.  If you do not receive a timely response, you should call the Practice directly or try an alternate means of communication.  In order to receive a response by e-mail or text message, you will be required to sign the Practice’s form outlining its policy on unsecured electronic communications. Again, all medical emergencies should be directed to 911, not the Practice.


3.3 Same Day/Next Day Appointments.  If you call or e-mail the Practice prior to noon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort will be made to schedule an appointment on the same day.  If you call or e-mail the Practice after noon on a normal office day to schedule an appointment, every reasonable effort will be made to schedule an appointment on the following day.  In any event, however, the Practice will make every reasonable effort to schedule an appointment for you on the same day that the request is made.  The Practice may satisfy its obligation to provide a prompt appointment under this section by scheduling a virtual/telemedicine visit with one of its providers if an in-office appointment is unavailable. The best way to schedule your appointment is via the website/patient portal or App. You may also walk in.


3.4 Hospital Visits.  Treatment in a hospital is not provided.  


3.5 Vaccines.  The Practice may, at your request, administer routine vaccinations when available.  The office visit for vaccine administration is covered by this Agreement, and is included in your membership fee.  However, the cost of the vaccine is not included.  Exact pricing for vaccinations is available upon request and will vary from time to time as suppliers adjust their pricing.



ARTICLE 4 – TERM AND TERMINATION


4.1 Term.  This Agreement will commence as of the date the last party signs it and will extend for one (1) year from that date.  Either party may terminate this Agreement at any time upon thirty (30) days written notice, however, no portion of the Enrollment Fee will be refundable.  However, if the Practice terminates this Agreement or stops providing direct care services, any monthly membership fees you paid in advance will be refunded to you as required by Florida law.


4.2 Renewal  This Agreement will automatically renew for additional one (1) year periods if neither you nor the Practice gives written notice that it does not want this Agreement to renew at least thirty (30) days prior to the current expiration date.  The Practice reserves the right to amend this Agreement on an annual basis to reflect certain operational changes and costs of operation.  The Practice will provide written notice of any change in terms as soon as reasonably practicable prior to the expiration date.  If Practice provides less than thirty (30) days’ notice of proposed changes, your obligation to provide thirty (30) days’ notice of intent not to renew is waived.  Should Practice provide appropriate notice of changes and you do not give timely notice that you do not want to renew, the Agreement will renew on the modified terms provided by the Practice.


4.2 The Practice may terminate your membership if you, or any member of your family, behave in an abusive or improper manner, or, if you fail to pay any fee or charge due for services.  In the event that the Practice exercises its right to terminate this Agreement for abusive or improper behavior or for failure to pay any fees or charges, the Practice is under no obligation to refund any portion of the Enrollment Fee or any Monthly Membership Fee, except those monthly membership fees you may have paid in advance.





ARTICLE 5 – NON-PARTICIPATION IN INSURANCE AND MEDICARE


5.1 Notice of Non-Participation Status.  As a direct care practice, the Practice does not participate in Medicare, Medicaid, Tricare, or any other government or private insurance plan.  As stated above, the Practice will not bill any services to an insurance company of any kind.


You acknowledge that the Practice does not participate in your health insurance, HMO, PPO, or POS plan or panel in any way and/or has OPTED OUT OF MEDICARE or is otherwise a NON-PARTICIPATING PROVIDER.  Neither the Practice nor its providers make any representation whatsoever that any fee for services provided by the Practice is covered by, or reimbursable by, your health insurance or by other third party discount or payment plans in which you or your family may be enrolled.  You will have the full and complete responsibility for any and all charges of the Practice not covered by your membership/subscription fee.  If you are eligible for Medicare, Medicaid, CHIP, or any other federal or state funded health plan, or become eligible during the term of this Agreement, then you agree to sign Schedule D.


5.2 Services Offered Are Not Insurance.  You understand and acknowledge that this Agreement does not provide health insurance coverage, including the minimal essential coverage required by applicable federal or state law.  It provides only the services described herein. It is recommended that health care insurance be obtained to cover medical services not provided for under this Agreement.



ARTICLE 6 – ARBITRATION


6.1 Arbitration of Disputes. In the event of any controversy or claim arising out of this Agreement, you agree that the dispute will be settled by submission to mandatory, confidential, and binding arbitration.  A copy of the Practice’s current arbitration policy is available upon request and incorporated into this section.  If not policy is in place, then arbitration will be before the American Health Lawyers Association’s Alternative Dispute Resolution Service employing its then-current arbitration rules.


ARTICLE 7 – COMMUNICATIONS


7.1 Unsecured Electronic Communication.  You acknowledge that communications with the Practice using fax, e-mail, and text are not guaranteed to be secure or confidential.  As such, you expressly waive the Practice’s obligation to ensure confidentiality with respect to unsolicited fax, e-mail, or text message communication.  


7.2 Al Communications Part of Record.  All communications with the Provider, regardless of form, may become a part of your medical records which may be produced to third parties in accordance with the law.

7.3 Acknowledgement Regarding E-mail Communication.  In authorizing the Practice to communicate with you by e-mail regarding your “protected health information” (PHI) using your e-mail address shown on the attached Schedule A, you acknowledge that:


7.3.1 E-mail is not a secure means for sending or receiving PHI and, in particular, if you send or receive e-mail through your employer’s email system, the employer may have the right to review it;


7.3.2 Although the Practice and the Provider will make reasonable efforts to keep e-mail communications confidential and secure, neither the Practice nor the Provider can assure or guarantee the confidentiality of e-mail communications;


7.3.3 In the discretion of the Provider, e-mail communications may be made a part of your permanent medical record; and


7.3.4 E-mail is not an appropriate means of communication regarding emergency or other time-sensitive issues or inquiries regarding sensitive information.


7.4 Unanswered/Delayed Responses to Communications.  If you do not receive a response to your e-mail message within one business day, you agree to use another means of communication to contact the Practice.  Neither the Practice nor its providers will be liable to you for any loss, cost, injury or expense caused by, or resulting from a delay in responding to you as a result of technical failures, including, but not limited to, (i) technical failures attributable to any internet service provider; (ii) power outages, failure of any electronic messaging software, failure to properly address e-mail messages; (iii) failure of the Practice’s computers or computer network, or faulty telephone or cable data transmission; (iv) any interception of e-mail communications by a third party; or (v) your failure to comply with the guidelines regarding use of e-mail communications in this paragraph.


Urgent, but non-emergency, medical questions or concerns should be communicated by telephone directly to the Practice.  If you are unable to reach the Practice by telephone, you agree to contact 911 immediately.



ARTICLE 8 – INSURANCE OR OTHER MEDICAL COVERAGE


8.1 Not Insurance.  This Agreement is not a substitute for health insurance or other health plan coverage (such as membership in an HMO, PPO, or POS).  This Agreement is not the purchase of insurance and is not enrollment in a health plan.  You agree that the Practice has advised you to purchase or keep in full force your health insurance policy(ies) or plans in order to cover you and your family members for healthcare costs not within the definition of Medical Services under this Agreement (or if this Agreement is terminated) and to prevent gaps in health coverage.


8.2 Referrals.  You understand and agree that from time to time, the Practice may order certain diagnostic/laboratory tests/point of care tests/injections that are not included in your membership or make referrals to a specialist.  The fees associated with those tests and evaluations by other providers are not covered and will not be reimbursed or credited in any way by the Practice.  You are responsible for arranging payment with those other providers directly.



ARTICLE 9 – OTHER TERMS


9.1 Assignability. You may not assign this Agreement or any rights you may have under it.  The Practice may assign this Agreement to an entity that purchases all of its assets or stock, or to another entity following an internal corporate reorganization.


9.2 Notices. All notices, requests, demands and other communications required or permitted under this Agreement must be in writing and delivered to the Practice at the address listed above.


9.3 Severability; Payment.  If for any reason any provision of this Agreement is deemed, by a court, to be legally invalid or unenforceable, the remainder of the Agreement is not affected.  The parties agree to modify the problematic provision to the minimum extent necessary to make it consistent with the law.  If for any reason the entire Agreement is held to be invalid, the Practice is entitled to a reasonable payment for the Services provided to you and your family members.


9.4 Legal Significance.  You acknowledge that this Agreement is a legal document and creates certain rights and responsibilities.  You also acknowledge that you have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.


9.5 Attached Schedules/Amendments. The attached Schedules A through D are incorporated into this Agreement.


9.6 Governing Law.  This Agreement is governed by the laws of the state of Florida.  All disputes not settled by arbitration must be resolved in the state or federal courts in or for Orange County, Florida.


9.7 Venue.  Venue for any arbitration or other legal proceeding lies in Orange County, Florida.  The parties waive any challenge to venue on any and all grounds including forum non conveniens.


9.8 Entire Agreement. This Agreement contains the entire understanding of the parties and supersedes all prior and contemporaneous agreements and understandings, inducements, or conditions, express or implied, oral or written, except as stated in the terms of this Agreement.


9.9 Amendment. This Agreement may not be modified or amended other than in writing and signed by all parties.


******** SIGNATURE PAGE TO FOLLOW ********


SECTION 624.27(4)(h), FLORIDA STATUTES, DISCLOSURE


THIS AGREEMENT IS NOT HEALTH INSURANCE AND THE PRIMARY CARE PROVIDER WILL NOT FILE ANY CLAIMS AGAINST THE PATIENT’S HEALTH INSURANCE POLICY OR PLAN FOR REIMBURSEMENT OF ANY PRIMARY CARE SERVICES COVERED BY THE AGREEMENT. THIS AGREEMENT DOES NOT QUALIFY AS MINIMUM ESSENTIAL COVERAGE TO SATISFY THE INDIVIDUAL SHARED RESPONSIBILITY PROVISION OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT, 26 U.S.C. S. 5000A. THIS AGREEMENT IS NOT WORKERS’ COMPENSATION INSURANCE AND DOES NOT REPLACE AN EMPLOYER’S OBLIGATIONS UNDER CHAPTER 440.


Attachments:

Schedule A:  Membership Enrollment Form

Schedule B:  Fee Schedule

Schedule C:  Menu of Services/Membership Benefits

Schedule D: Medicare Opt-Out Agreement/Member Signature

Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.

BOUTIQ MEDICAL CLINIC, LLC

PATIENT MEMBERSHIP AGREEMENT


This Membership Agreement is a contract for medical services to be provided by Boutiq Medical Clinic, LLC, and is effective as of the last date entered below.


Boutiq Medical Clinic, LLC (“Practice”), is a direct care practice, serving ages 7 and older, that currently aims to supplant the traditional insurance-based care model with conventional and innovative care delivery methods and services for a membership/subscription fee.


The Practice provides a range of family, pediatric, and other health services to its patients.


The Practice, is independently owned and operated, and employs different types of medical providers for the purpose of treating its patients.


The Practice is located at 1430 N. Mills avenue, Suite 120, Orlando, Florida 32803, and all office-based services are provided at that location.


The Practice’s regular hours are as follows:


Monday through Friday- 8am to 6pm

Saturday- 9am to 2pm

Sunday- Closed


At the Practice’s discretion, limited appointments may be made available on days and at times when it would normally be closed. Regular hours may vary.


During hours when the main office is closed, or during the business day, and when appropriate, the Practice may elect to provide virtual/telemedicine services to its patients.  No guarantee is made that these services will in fact be offered.


The terms “you” or “the Patient” refers to the patient whose signature appears on the signature page of this Agreement.  If the signature page or any schedule attached to this Agreement indicates that the term “you” or “the Patient” is intended to mean a couple or family (parents and children), then any references in this Agreement will mean each member of your family.


By signing this Agreement you are stating that you want to receive, in exchange for a fee, certain medical and non-medical services (collectively the "Services") from the Practice as part of your membership in the Practice.


The purpose of this Agreement is to define how and what Services will be furnished to you by the Practice.


ARTICLE 1 - PAYMENT


1.1 In exchange for the services provided for in this Agreement, you agree to pay the Practice the fees for the services you request as listed on the Fee List in Schedule B.


ARTICLE 2 - MEDICAL SERVICES


2.1 The Practice will provide you with the Services listed on the Menu of Services in Schedule C.  In this Agreement, the term Medical Services means the services that the Practice’s providers personally provide, as well as those services that staff members are permitted to provide at the direction or under supervision pursuant to the laws of the State of Florida.  Generally, Medical Services include health promotion, disease prevention, diagnosis, care, and treatment of patients during all stages of life.  Medical Services specifically include and exclude those items listed in Schedule C.


2.2 Alternate Provider.  Member understands that the Practice’s primary provider may be unavailable to provide services at times due to patient care obligations, illness, injury, vacation or other similar obligations.  During those particular times, the Practice will reasonably attempt to make arrangements to ensure another provider is able to assist you with your medical needs, or to be available via remote means of communication (i.e. through telemedicine).  The substitute provider may be, as permitted by law:  a substitute physician; nurse practitioner; registered nurse; physician assistant; or medical assistant.


2.3 Billing to Insurance Companies.  The Practice will provide the full range of services normally provided by a primary care physician in an office, via telemedicine, or in house call settings.  The Practice will not, even if covered by your primary insurance policy, bill those services to the insurance company or accept as payment in full, the reimbursement remitted by the insurer.  The Practice will, at its discretion, provide you with an explanation of the services provided by it so that you can seek reimbursement from your own insurer, if any.  The Practice will not communicate with the insurance company, nor will it change or modify its medical decision-making based on what your insurance company may, or may not, reimburse.



ARTICLE 3 - NON-MEDICAL SERVICES


3.1 24/7 Access; After Hours Care.  As a member of the Practice you will have direct access to the Practice’s providers via the patient portal (registration required by you) on a twenty-four hour per day, seven day per week basis for non-urgent matters. The Providers will respond as time permits. During the Provider's absence for vacations, continuing medical education, illness, emergencies, or normal days off, the Practice will be unavailable.  You acknowledge that the Practice’s providers may, from time to time, not be available at the times referred to above.


If at any time you experience an emergency medical situation that is life threatening or of a serious nature, you should NOT call or message the Practice but instead you should CALL 911 IMMEDIATELY.


3.2 Fax and E-Mail Access. You will be given the Practice’s fax number and e-mail address to which you can send non-urgent messages.  These communications will be handled by a staff member of the Practice in a timely manner, including a reasonably prompt response to you by the Provider or by the staff member.  E-mails will typically receive a response within twenty-four (24) hours.  If you do not receive a timely response, you should call the Practice directly or try an alternate means of communication.  In order to receive a response by e-mail or text message, you will be required to sign the Practice’s form outlining its policy on unsecured electronic communications. Again, all medical emergencies should be directed to 911, not the Practice.


3.3 Same Day/Next Day Appointments.  If you call or e-mail the Practice prior to noon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort will be made to schedule an appointment on the same day.  If you call or e-mail the Practice after noon on a normal office day to schedule an appointment, every reasonable effort will be made to schedule an appointment on the following day.  In any event, however, the Practice will make every reasonable effort to schedule an appointment for you on the same day that the request is made.  The Practice may satisfy its obligation to provide a prompt appointment under this section by scheduling a virtual/telemedicine visit with one of its providers if an in-office appointment is unavailable. The best way to schedule your appointment is via the website/patient portal or App. You may also walk in.


3.4 Hospital Visits.  Treatment in a hospital is not provided.  


3.5 Vaccines.  The Practice may, at your request, administer routine vaccinations when available.  The office visit for vaccine administration is covered by this Agreement, and is included in your membership fee.  However, the cost of the vaccine is not included.  Exact pricing for vaccinations is available upon request and will vary from time to time as suppliers adjust their pricing.



ARTICLE 4 – TERM AND TERMINATION


4.1 Term.  This Agreement will commence as of the date the last party signs it and will extend for one (1) year from that date.  Either party may terminate this Agreement at any time upon thirty (30) days written notice, however, no portion of the Enrollment Fee will be refundable.  However, if the Practice terminates this Agreement or stops providing direct care services, any monthly membership fees you paid in advance will be refunded to you as required by Florida law.


4.2 Renewal  This Agreement will automatically renew for additional one (1) year periods if neither you nor the Practice gives written notice that it does not want this Agreement to renew at least thirty (30) days prior to the current expiration date.  The Practice reserves the right to amend this Agreement on an annual basis to reflect certain operational changes and costs of operation.  The Practice will provide written notice of any change in terms as soon as reasonably practicable prior to the expiration date.  If Practice provides less than thirty (30) days’ notice of proposed changes, your obligation to provide thirty (30) days’ notice of intent not to renew is waived.  Should Practice provide appropriate notice of changes and you do not give timely notice that you do not want to renew, the Agreement will renew on the modified terms provided by the Practice.


4.2 The Practice may terminate your membership if you, or any member of your family, behave in an abusive or improper manner, or, if you fail to pay any fee or charge due for services.  In the event that the Practice exercises its right to terminate this Agreement for abusive or improper behavior or for failure to pay any fees or charges, the Practice is under no obligation to refund any portion of the Enrollment Fee or any Monthly Membership Fee, except those monthly membership fees you may have paid in advance.





ARTICLE 5 – NON-PARTICIPATION IN INSURANCE AND MEDICARE


5.1 Notice of Non-Participation Status.  As a direct care practice, the Practice does not participate in Medicare, Medicaid, Tricare, or any other government or private insurance plan.  As stated above, the Practice will not bill any services to an insurance company of any kind.


You acknowledge that the Practice does not participate in your health insurance, HMO, PPO, or POS plan or panel in any way and/or has OPTED OUT OF MEDICARE or is otherwise a NON-PARTICIPATING PROVIDER.  Neither the Practice nor its providers make any representation whatsoever that any fee for services provided by the Practice is covered by, or reimbursable by, your health insurance or by other third party discount or payment plans in which you or your family may be enrolled.  You will have the full and complete responsibility for any and all charges of the Practice not covered by your membership/subscription fee.  If you are eligible for Medicare, Medicaid, CHIP, or any other federal or state funded health plan, or become eligible during the term of this Agreement, then you agree to sign Schedule D.


5.2 Services Offered Are Not Insurance.  You understand and acknowledge that this Agreement does not provide health insurance coverage, including the minimal essential coverage required by applicable federal or state law.  It provides only the services described herein. It is recommended that health care insurance be obtained to cover medical services not provided for under this Agreement.



ARTICLE 6 – ARBITRATION


6.1 Arbitration of Disputes. In the event of any controversy or claim arising out of this Agreement, you agree that the dispute will be settled by submission to mandatory, confidential, and binding arbitration.  A copy of the Practice’s current arbitration policy is available upon request and incorporated into this section.  If not policy is in place, then arbitration will be before the American Health Lawyers Association’s Alternative Dispute Resolution Service employing its then-current arbitration rules.


ARTICLE 7 – COMMUNICATIONS


7.1 Unsecured Electronic Communication.  You acknowledge that communications with the Practice using fax, e-mail, and text are not guaranteed to be secure or confidential.  As such, you expressly waive the Practice’s obligation to ensure confidentiality with respect to unsolicited fax, e-mail, or text message communication.  


7.2 Al Communications Part of Record.  All communications with the Provider, regardless of form, may become a part of your medical records which may be produced to third parties in accordance with the law.

7.3 Acknowledgement Regarding E-mail Communication.  In authorizing the Practice to communicate with you by e-mail regarding your “protected health information” (PHI) using your e-mail address shown on the attached Schedule A, you acknowledge that:


7.3.1 E-mail is not a secure means for sending or receiving PHI and, in particular, if you send or receive e-mail through your employer’s email system, the employer may have the right to review it;


7.3.2 Although the Practice and the Provider will make reasonable efforts to keep e-mail communications confidential and secure, neither the Practice nor the Provider can assure or guarantee the confidentiality of e-mail communications;


7.3.3 In the discretion of the Provider, e-mail communications may be made a part of your permanent medical record; and


7.3.4 E-mail is not an appropriate means of communication regarding emergency or other time-sensitive issues or inquiries regarding sensitive information.


7.4 Unanswered/Delayed Responses to Communications.  If you do not receive a response to your e-mail message within one business day, you agree to use another means of communication to contact the Practice.  Neither the Practice nor its providers will be liable to you for any loss, cost, injury or expense caused by, or resulting from a delay in responding to you as a result of technical failures, including, but not limited to, (i) technical failures attributable to any internet service provider; (ii) power outages, failure of any electronic messaging software, failure to properly address e-mail messages; (iii) failure of the Practice’s computers or computer network, or faulty telephone or cable data transmission; (iv) any interception of e-mail communications by a third party; or (v) your failure to comply with the guidelines regarding use of e-mail communications in this paragraph.


Urgent, but non-emergency, medical questions or concerns should be communicated by telephone directly to the Practice.  If you are unable to reach the Practice by telephone, you agree to contact 911 immediately.



ARTICLE 8 – INSURANCE OR OTHER MEDICAL COVERAGE


8.1 Not Insurance.  This Agreement is not a substitute for health insurance or other health plan coverage (such as membership in an HMO, PPO, or POS).  This Agreement is not the purchase of insurance and is not enrollment in a health plan.  You agree that the Practice has advised you to purchase or keep in full force your health insurance policy(ies) or plans in order to cover you and your family members for healthcare costs not within the definition of Medical Services under this Agreement (or if this Agreement is terminated) and to prevent gaps in health coverage.


8.2 Referrals.  You understand and agree that from time to time, the Practice may order certain diagnostic/laboratory tests/point of care tests/injections that are not included in your membership or make referrals to a specialist.  The fees associated with those tests and evaluations by other providers are not covered and will not be reimbursed or credited in any way by the Practice.  You are responsible for arranging payment with those other providers directly.



ARTICLE 9 – OTHER TERMS


9.1 Assignability. You may not assign this Agreement or any rights you may have under it.  The Practice may assign this Agreement to an entity that purchases all of its assets or stock, or to another entity following an internal corporate reorganization.


9.2 Notices. All notices, requests, demands and other communications required or permitted under this Agreement must be in writing and delivered to the Practice at the address listed above.


9.3 Severability; Payment.  If for any reason any provision of this Agreement is deemed, by a court, to be legally invalid or unenforceable, the remainder of the Agreement is not affected.  The parties agree to modify the problematic provision to the minimum extent necessary to make it consistent with the law.  If for any reason the entire Agreement is held to be invalid, the Practice is entitled to a reasonable payment for the Services provided to you and your family members.


9.4 Legal Significance.  You acknowledge that this Agreement is a legal document and creates certain rights and responsibilities.  You also acknowledge that you have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.


9.5 Attached Schedules/Amendments. The attached Schedules A through D are incorporated into this Agreement.


9.6 Governing Law.  This Agreement is governed by the laws of the state of Florida.  All disputes not settled by arbitration must be resolved in the state or federal courts in or for Orange County, Florida.


9.7 Venue.  Venue for any arbitration or other legal proceeding lies in Orange County, Florida.  The parties waive any challenge to venue on any and all grounds including forum non conveniens.


9.8 Entire Agreement. This Agreement contains the entire understanding of the parties and supersedes all prior and contemporaneous agreements and understandings, inducements, or conditions, express or implied, oral or written, except as stated in the terms of this Agreement.


9.9 Amendment. This Agreement may not be modified or amended other than in writing and signed by all parties.


******** SIGNATURE PAGE TO FOLLOW ********


SECTION 624.27(4)(h), FLORIDA STATUTES, DISCLOSURE


THIS AGREEMENT IS NOT HEALTH INSURANCE AND THE PRIMARY CARE PROVIDER WILL NOT FILE ANY CLAIMS AGAINST THE PATIENT’S HEALTH INSURANCE POLICY OR PLAN FOR REIMBURSEMENT OF ANY PRIMARY CARE SERVICES COVERED BY THE AGREEMENT. THIS AGREEMENT DOES NOT QUALIFY AS MINIMUM ESSENTIAL COVERAGE TO SATISFY THE INDIVIDUAL SHARED RESPONSIBILITY PROVISION OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT, 26 U.S.C. S. 5000A. THIS AGREEMENT IS NOT WORKERS’ COMPENSATION INSURANCE AND DOES NOT REPLACE AN EMPLOYER’S OBLIGATIONS UNDER CHAPTER 440.


Attachments:

Schedule A:  Membership Enrollment Form

Schedule B:  Fee Schedule

Schedule C:  Menu of Services/Membership Benefits

Schedule D: Medicare Opt-Out Agreement/Member Signature

Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.

BOUTIQ MEDICAL CLINIC, LLC

PATIENT MEMBERSHIP AGREEMENT


This Membership Agreement is a contract for medical services to be provided by Boutiq Medical Clinic, LLC, and is effective as of the last date entered below.


Boutiq Medical Clinic, LLC (“Practice”), is a direct care practice, serving ages 7 and older, that currently aims to supplant the traditional insurance-based care model with conventional and innovative care delivery methods and services for a membership/subscription fee.


The Practice provides a range of family, pediatric, and other health services to its patients.


The Practice, is independently owned and operated, and employs different types of medical providers for the purpose of treating its patients.


The Practice is located at 1430 N. Mills avenue, Suite 120, Orlando, Florida 32803, and all office-based services are provided at that location.


The Practice’s regular hours are as follows:


Monday through Friday- 8am to 6pm

Saturday- 9am to 2pm

Sunday- Closed


At the Practice’s discretion, limited appointments may be made available on days and at times when it would normally be closed. Regular hours may vary.


During hours when the main office is closed, or during the business day, and when appropriate, the Practice may elect to provide virtual/telemedicine services to its patients.  No guarantee is made that these services will in fact be offered.


The terms “you” or “the Patient” refers to the patient whose signature appears on the signature page of this Agreement.  If the signature page or any schedule attached to this Agreement indicates that the term “you” or “the Patient” is intended to mean a couple or family (parents and children), then any references in this Agreement will mean each member of your family.


By signing this Agreement you are stating that you want to receive, in exchange for a fee, certain medical and non-medical services (collectively the "Services") from the Practice as part of your membership in the Practice.


The purpose of this Agreement is to define how and what Services will be furnished to you by the Practice.


ARTICLE 1 - PAYMENT


1.1 In exchange for the services provided for in this Agreement, you agree to pay the Practice the fees for the services you request as listed on the Fee List in Schedule B.


ARTICLE 2 - MEDICAL SERVICES


2.1 The Practice will provide you with the Services listed on the Menu of Services in Schedule C.  In this Agreement, the term Medical Services means the services that the Practice’s providers personally provide, as well as those services that staff members are permitted to provide at the direction or under supervision pursuant to the laws of the State of Florida.  Generally, Medical Services include health promotion, disease prevention, diagnosis, care, and treatment of patients during all stages of life.  Medical Services specifically include and exclude those items listed in Schedule C.


2.2 Alternate Provider.  Member understands that the Practice’s primary provider may be unavailable to provide services at times due to patient care obligations, illness, injury, vacation or other similar obligations.  During those particular times, the Practice will reasonably attempt to make arrangements to ensure another provider is able to assist you with your medical needs, or to be available via remote means of communication (i.e. through telemedicine).  The substitute provider may be, as permitted by law:  a substitute physician; nurse practitioner; registered nurse; physician assistant; or medical assistant.


2.3 Billing to Insurance Companies.  The Practice will provide the full range of services normally provided by a primary care physician in an office, via telemedicine, or in house call settings.  The Practice will not, even if covered by your primary insurance policy, bill those services to the insurance company or accept as payment in full, the reimbursement remitted by the insurer.  The Practice will, at its discretion, provide you with an explanation of the services provided by it so that you can seek reimbursement from your own insurer, if any.  The Practice will not communicate with the insurance company, nor will it change or modify its medical decision-making based on what your insurance company may, or may not, reimburse.



ARTICLE 3 - NON-MEDICAL SERVICES


3.1 24/7 Access; After Hours Care.  As a member of the Practice you will have direct access to the Practice’s providers via the patient portal (registration required by you) on a twenty-four hour per day, seven day per week basis for non-urgent matters. The Providers will respond as time permits. During the Provider's absence for vacations, continuing medical education, illness, emergencies, or normal days off, the Practice will be unavailable.  You acknowledge that the Practice’s providers may, from time to time, not be available at the times referred to above.


If at any time you experience an emergency medical situation that is life threatening or of a serious nature, you should NOT call or message the Practice but instead you should CALL 911 IMMEDIATELY.


3.2 Fax and E-Mail Access. You will be given the Practice’s fax number and e-mail address to which you can send non-urgent messages.  These communications will be handled by a staff member of the Practice in a timely manner, including a reasonably prompt response to you by the Provider or by the staff member.  E-mails will typically receive a response within twenty-four (24) hours.  If you do not receive a timely response, you should call the Practice directly or try an alternate means of communication.  In order to receive a response by e-mail or text message, you will be required to sign the Practice’s form outlining its policy on unsecured electronic communications. Again, all medical emergencies should be directed to 911, not the Practice.


3.3 Same Day/Next Day Appointments.  If you call or e-mail the Practice prior to noon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort will be made to schedule an appointment on the same day.  If you call or e-mail the Practice after noon on a normal office day to schedule an appointment, every reasonable effort will be made to schedule an appointment on the following day.  In any event, however, the Practice will make every reasonable effort to schedule an appointment for you on the same day that the request is made.  The Practice may satisfy its obligation to provide a prompt appointment under this section by scheduling a virtual/telemedicine visit with one of its providers if an in-office appointment is unavailable. The best way to schedule your appointment is via the website/patient portal or App. You may also walk in.


3.4 Hospital Visits.  Treatment in a hospital is not provided.  


3.5 Vaccines.  The Practice may, at your request, administer routine vaccinations when available.  The office visit for vaccine administration is covered by this Agreement, and is included in your membership fee.  However, the cost of the vaccine is not included.  Exact pricing for vaccinations is available upon request and will vary from time to time as suppliers adjust their pricing.



ARTICLE 4 – TERM AND TERMINATION


4.1 Term.  This Agreement will commence as of the date the last party signs it and will extend for one (1) year from that date.  Either party may terminate this Agreement at any time upon thirty (30) days written notice, however, no portion of the Enrollment Fee will be refundable.  However, if the Practice terminates this Agreement or stops providing direct care services, any monthly membership fees you paid in advance will be refunded to you as required by Florida law.


4.2 Renewal  This Agreement will automatically renew for additional one (1) year periods if neither you nor the Practice gives written notice that it does not want this Agreement to renew at least thirty (30) days prior to the current expiration date.  The Practice reserves the right to amend this Agreement on an annual basis to reflect certain operational changes and costs of operation.  The Practice will provide written notice of any change in terms as soon as reasonably practicable prior to the expiration date.  If Practice provides less than thirty (30) days’ notice of proposed changes, your obligation to provide thirty (30) days’ notice of intent not to renew is waived.  Should Practice provide appropriate notice of changes and you do not give timely notice that you do not want to renew, the Agreement will renew on the modified terms provided by the Practice.


4.2 The Practice may terminate your membership if you, or any member of your family, behave in an abusive or improper manner, or, if you fail to pay any fee or charge due for services.  In the event that the Practice exercises its right to terminate this Agreement for abusive or improper behavior or for failure to pay any fees or charges, the Practice is under no obligation to refund any portion of the Enrollment Fee or any Monthly Membership Fee, except those monthly membership fees you may have paid in advance.





ARTICLE 5 – NON-PARTICIPATION IN INSURANCE AND MEDICARE


5.1 Notice of Non-Participation Status.  As a direct care practice, the Practice does not participate in Medicare, Medicaid, Tricare, or any other government or private insurance plan.  As stated above, the Practice will not bill any services to an insurance company of any kind.


You acknowledge that the Practice does not participate in your health insurance, HMO, PPO, or POS plan or panel in any way and/or has OPTED OUT OF MEDICARE or is otherwise a NON-PARTICIPATING PROVIDER.  Neither the Practice nor its providers make any representation whatsoever that any fee for services provided by the Practice is covered by, or reimbursable by, your health insurance or by other third party discount or payment plans in which you or your family may be enrolled.  You will have the full and complete responsibility for any and all charges of the Practice not covered by your membership/subscription fee.  If you are eligible for Medicare, Medicaid, CHIP, or any other federal or state funded health plan, or become eligible during the term of this Agreement, then you agree to sign Schedule D.


5.2 Services Offered Are Not Insurance.  You understand and acknowledge that this Agreement does not provide health insurance coverage, including the minimal essential coverage required by applicable federal or state law.  It provides only the services described herein. It is recommended that health care insurance be obtained to cover medical services not provided for under this Agreement.



ARTICLE 6 – ARBITRATION


6.1 Arbitration of Disputes. In the event of any controversy or claim arising out of this Agreement, you agree that the dispute will be settled by submission to mandatory, confidential, and binding arbitration.  A copy of the Practice’s current arbitration policy is available upon request and incorporated into this section.  If not policy is in place, then arbitration will be before the American Health Lawyers Association’s Alternative Dispute Resolution Service employing its then-current arbitration rules.


ARTICLE 7 – COMMUNICATIONS


7.1 Unsecured Electronic Communication.  You acknowledge that communications with the Practice using fax, e-mail, and text are not guaranteed to be secure or confidential.  As such, you expressly waive the Practice’s obligation to ensure confidentiality with respect to unsolicited fax, e-mail, or text message communication.  


7.2 Al Communications Part of Record.  All communications with the Provider, regardless of form, may become a part of your medical records which may be produced to third parties in accordance with the law.

7.3 Acknowledgement Regarding E-mail Communication.  In authorizing the Practice to communicate with you by e-mail regarding your “protected health information” (PHI) using your e-mail address shown on the attached Schedule A, you acknowledge that:


7.3.1 E-mail is not a secure means for sending or receiving PHI and, in particular, if you send or receive e-mail through your employer’s email system, the employer may have the right to review it;


7.3.2 Although the Practice and the Provider will make reasonable efforts to keep e-mail communications confidential and secure, neither the Practice nor the Provider can assure or guarantee the confidentiality of e-mail communications;


7.3.3 In the discretion of the Provider, e-mail communications may be made a part of your permanent medical record; and


7.3.4 E-mail is not an appropriate means of communication regarding emergency or other time-sensitive issues or inquiries regarding sensitive information.


7.4 Unanswered/Delayed Responses to Communications.  If you do not receive a response to your e-mail message within one business day, you agree to use another means of communication to contact the Practice.  Neither the Practice nor its providers will be liable to you for any loss, cost, injury or expense caused by, or resulting from a delay in responding to you as a result of technical failures, including, but not limited to, (i) technical failures attributable to any internet service provider; (ii) power outages, failure of any electronic messaging software, failure to properly address e-mail messages; (iii) failure of the Practice’s computers or computer network, or faulty telephone or cable data transmission; (iv) any interception of e-mail communications by a third party; or (v) your failure to comply with the guidelines regarding use of e-mail communications in this paragraph.


Urgent, but non-emergency, medical questions or concerns should be communicated by telephone directly to the Practice.  If you are unable to reach the Practice by telephone, you agree to contact 911 immediately.



ARTICLE 8 – INSURANCE OR OTHER MEDICAL COVERAGE


8.1 Not Insurance.  This Agreement is not a substitute for health insurance or other health plan coverage (such as membership in an HMO, PPO, or POS).  This Agreement is not the purchase of insurance and is not enrollment in a health plan.  You agree that the Practice has advised you to purchase or keep in full force your health insurance policy(ies) or plans in order to cover you and your family members for healthcare costs not within the definition of Medical Services under this Agreement (or if this Agreement is terminated) and to prevent gaps in health coverage.


8.2 Referrals.  You understand and agree that from time to time, the Practice may order certain diagnostic/laboratory tests/point of care tests/injections that are not included in your membership or make referrals to a specialist.  The fees associated with those tests and evaluations by other providers are not covered and will not be reimbursed or credited in any way by the Practice.  You are responsible for arranging payment with those other providers directly.



ARTICLE 9 – OTHER TERMS


9.1 Assignability. You may not assign this Agreement or any rights you may have under it.  The Practice may assign this Agreement to an entity that purchases all of its assets or stock, or to another entity following an internal corporate reorganization.


9.2 Notices. All notices, requests, demands and other communications required or permitted under this Agreement must be in writing and delivered to the Practice at the address listed above.


9.3 Severability; Payment.  If for any reason any provision of this Agreement is deemed, by a court, to be legally invalid or unenforceable, the remainder of the Agreement is not affected.  The parties agree to modify the problematic provision to the minimum extent necessary to make it consistent with the law.  If for any reason the entire Agreement is held to be invalid, the Practice is entitled to a reasonable payment for the Services provided to you and your family members.


9.4 Legal Significance.  You acknowledge that this Agreement is a legal document and creates certain rights and responsibilities.  You also acknowledge that you have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.


9.5 Attached Schedules/Amendments. The attached Schedules A through D are incorporated into this Agreement.


9.6 Governing Law.  This Agreement is governed by the laws of the state of Florida.  All disputes not settled by arbitration must be resolved in the state or federal courts in or for Orange County, Florida.


9.7 Venue.  Venue for any arbitration or other legal proceeding lies in Orange County, Florida.  The parties waive any challenge to venue on any and all grounds including forum non conveniens.


9.8 Entire Agreement. This Agreement contains the entire understanding of the parties and supersedes all prior and contemporaneous agreements and understandings, inducements, or conditions, express or implied, oral or written, except as stated in the terms of this Agreement.


9.9 Amendment. This Agreement may not be modified or amended other than in writing and signed by all parties.


******** SIGNATURE PAGE TO FOLLOW ********


SECTION 624.27(4)(h), FLORIDA STATUTES, DISCLOSURE


THIS AGREEMENT IS NOT HEALTH INSURANCE AND THE PRIMARY CARE PROVIDER WILL NOT FILE ANY CLAIMS AGAINST THE PATIENT’S HEALTH INSURANCE POLICY OR PLAN FOR REIMBURSEMENT OF ANY PRIMARY CARE SERVICES COVERED BY THE AGREEMENT. THIS AGREEMENT DOES NOT QUALIFY AS MINIMUM ESSENTIAL COVERAGE TO SATISFY THE INDIVIDUAL SHARED RESPONSIBILITY PROVISION OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT, 26 U.S.C. S. 5000A. THIS AGREEMENT IS NOT WORKERS’ COMPENSATION INSURANCE AND DOES NOT REPLACE AN EMPLOYER’S OBLIGATIONS UNDER CHAPTER 440.


Attachments:

Schedule A:  Membership Enrollment Form

Schedule B:  Fee Schedule

Schedule C:  Menu of Services/Membership Benefits

Schedule D: Medicare Opt-Out Agreement/Member Signature

Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.

BOUTIQ MEDICAL CLINIC, LLC

PATIENT MEMBERSHIP AGREEMENT


This Membership Agreement is a contract for medical services to be provided by Boutiq Medical Clinic, LLC, and is effective as of the last date entered below.


Boutiq Medical Clinic, LLC (“Practice”), is a direct care practice, serving ages 7 and older, that currently aims to supplant the traditional insurance-based care model with conventional and innovative care delivery methods and services for a membership/subscription fee.


The Practice provides a range of family, pediatric, and other health services to its patients.


The Practice, is independently owned and operated, and employs different types of medical providers for the purpose of treating its patients.


The Practice is located at 1430 N. Mills avenue, Suite 120, Orlando, Florida 32803, and all office-based services are provided at that location.


The Practice’s regular hours are as follows:


Monday through Friday- 8am to 6pm

Saturday- 9am to 2pm

Sunday- Closed


At the Practice’s discretion, limited appointments may be made available on days and at times when it would normally be closed. Regular hours may vary.


During hours when the main office is closed, or during the business day, and when appropriate, the Practice may elect to provide virtual/telemedicine services to its patients.  No guarantee is made that these services will in fact be offered.


The terms “you” or “the Patient” refers to the patient whose signature appears on the signature page of this Agreement.  If the signature page or any schedule attached to this Agreement indicates that the term “you” or “the Patient” is intended to mean a couple or family (parents and children), then any references in this Agreement will mean each member of your family.


By signing this Agreement you are stating that you want to receive, in exchange for a fee, certain medical and non-medical services (collectively the "Services") from the Practice as part of your membership in the Practice.


The purpose of this Agreement is to define how and what Services will be furnished to you by the Practice.


ARTICLE 1 - PAYMENT


1.1 In exchange for the services provided for in this Agreement, you agree to pay the Practice the fees for the services you request as listed on the Fee List in Schedule B.


ARTICLE 2 - MEDICAL SERVICES


2.1 The Practice will provide you with the Services listed on the Menu of Services in Schedule C.  In this Agreement, the term Medical Services means the services that the Practice’s providers personally provide, as well as those services that staff members are permitted to provide at the direction or under supervision pursuant to the laws of the State of Florida.  Generally, Medical Services include health promotion, disease prevention, diagnosis, care, and treatment of patients during all stages of life.  Medical Services specifically include and exclude those items listed in Schedule C.


2.2 Alternate Provider.  Member understands that the Practice’s primary provider may be unavailable to provide services at times due to patient care obligations, illness, injury, vacation or other similar obligations.  During those particular times, the Practice will reasonably attempt to make arrangements to ensure another provider is able to assist you with your medical needs, or to be available via remote means of communication (i.e. through telemedicine).  The substitute provider may be, as permitted by law:  a substitute physician; nurse practitioner; registered nurse; physician assistant; or medical assistant.


2.3 Billing to Insurance Companies.  The Practice will provide the full range of services normally provided by a primary care physician in an office, via telemedicine, or in house call settings.  The Practice will not, even if covered by your primary insurance policy, bill those services to the insurance company or accept as payment in full, the reimbursement remitted by the insurer.  The Practice will, at its discretion, provide you with an explanation of the services provided by it so that you can seek reimbursement from your own insurer, if any.  The Practice will not communicate with the insurance company, nor will it change or modify its medical decision-making based on what your insurance company may, or may not, reimburse.



ARTICLE 3 - NON-MEDICAL SERVICES


3.1 24/7 Access; After Hours Care.  As a member of the Practice you will have direct access to the Practice’s providers via the patient portal (registration required by you) on a twenty-four hour per day, seven day per week basis for non-urgent matters. The Providers will respond as time permits. During the Provider's absence for vacations, continuing medical education, illness, emergencies, or normal days off, the Practice will be unavailable.  You acknowledge that the Practice’s providers may, from time to time, not be available at the times referred to above.


If at any time you experience an emergency medical situation that is life threatening or of a serious nature, you should NOT call or message the Practice but instead you should CALL 911 IMMEDIATELY.


3.2 Fax and E-Mail Access. You will be given the Practice’s fax number and e-mail address to which you can send non-urgent messages.  These communications will be handled by a staff member of the Practice in a timely manner, including a reasonably prompt response to you by the Provider or by the staff member.  E-mails will typically receive a response within twenty-four (24) hours.  If you do not receive a timely response, you should call the Practice directly or try an alternate means of communication.  In order to receive a response by e-mail or text message, you will be required to sign the Practice’s form outlining its policy on unsecured electronic communications. Again, all medical emergencies should be directed to 911, not the Practice.


3.3 Same Day/Next Day Appointments.  If you call or e-mail the Practice prior to noon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort will be made to schedule an appointment on the same day.  If you call or e-mail the Practice after noon on a normal office day to schedule an appointment, every reasonable effort will be made to schedule an appointment on the following day.  In any event, however, the Practice will make every reasonable effort to schedule an appointment for you on the same day that the request is made.  The Practice may satisfy its obligation to provide a prompt appointment under this section by scheduling a virtual/telemedicine visit with one of its providers if an in-office appointment is unavailable. The best way to schedule your appointment is via the website/patient portal or App. You may also walk in.


3.4 Hospital Visits.  Treatment in a hospital is not provided.  


3.5 Vaccines.  The Practice may, at your request, administer routine vaccinations when available.  The office visit for vaccine administration is covered by this Agreement, and is included in your membership fee.  However, the cost of the vaccine is not included.  Exact pricing for vaccinations is available upon request and will vary from time to time as suppliers adjust their pricing.



ARTICLE 4 – TERM AND TERMINATION


4.1 Term.  This Agreement will commence as of the date the last party signs it and will extend for one (1) year from that date.  Either party may terminate this Agreement at any time upon thirty (30) days written notice, however, no portion of the Enrollment Fee will be refundable.  However, if the Practice terminates this Agreement or stops providing direct care services, any monthly membership fees you paid in advance will be refunded to you as required by Florida law.


4.2 Renewal  This Agreement will automatically renew for additional one (1) year periods if neither you nor the Practice gives written notice that it does not want this Agreement to renew at least thirty (30) days prior to the current expiration date.  The Practice reserves the right to amend this Agreement on an annual basis to reflect certain operational changes and costs of operation.  The Practice will provide written notice of any change in terms as soon as reasonably practicable prior to the expiration date.  If Practice provides less than thirty (30) days’ notice of proposed changes, your obligation to provide thirty (30) days’ notice of intent not to renew is waived.  Should Practice provide appropriate notice of changes and you do not give timely notice that you do not want to renew, the Agreement will renew on the modified terms provided by the Practice.


4.2 The Practice may terminate your membership if you, or any member of your family, behave in an abusive or improper manner, or, if you fail to pay any fee or charge due for services.  In the event that the Practice exercises its right to terminate this Agreement for abusive or improper behavior or for failure to pay any fees or charges, the Practice is under no obligation to refund any portion of the Enrollment Fee or any Monthly Membership Fee, except those monthly membership fees you may have paid in advance.





ARTICLE 5 – NON-PARTICIPATION IN INSURANCE AND MEDICARE


5.1 Notice of Non-Participation Status.  As a direct care practice, the Practice does not participate in Medicare, Medicaid, Tricare, or any other government or private insurance plan.  As stated above, the Practice will not bill any services to an insurance company of any kind.


You acknowledge that the Practice does not participate in your health insurance, HMO, PPO, or POS plan or panel in any way and/or has OPTED OUT OF MEDICARE or is otherwise a NON-PARTICIPATING PROVIDER.  Neither the Practice nor its providers make any representation whatsoever that any fee for services provided by the Practice is covered by, or reimbursable by, your health insurance or by other third party discount or payment plans in which you or your family may be enrolled.  You will have the full and complete responsibility for any and all charges of the Practice not covered by your membership/subscription fee.  If you are eligible for Medicare, Medicaid, CHIP, or any other federal or state funded health plan, or become eligible during the term of this Agreement, then you agree to sign Schedule D.


5.2 Services Offered Are Not Insurance.  You understand and acknowledge that this Agreement does not provide health insurance coverage, including the minimal essential coverage required by applicable federal or state law.  It provides only the services described herein. It is recommended that health care insurance be obtained to cover medical services not provided for under this Agreement.



ARTICLE 6 – ARBITRATION


6.1 Arbitration of Disputes. In the event of any controversy or claim arising out of this Agreement, you agree that the dispute will be settled by submission to mandatory, confidential, and binding arbitration.  A copy of the Practice’s current arbitration policy is available upon request and incorporated into this section.  If not policy is in place, then arbitration will be before the American Health Lawyers Association’s Alternative Dispute Resolution Service employing its then-current arbitration rules.


ARTICLE 7 – COMMUNICATIONS


7.1 Unsecured Electronic Communication.  You acknowledge that communications with the Practice using fax, e-mail, and text are not guaranteed to be secure or confidential.  As such, you expressly waive the Practice’s obligation to ensure confidentiality with respect to unsolicited fax, e-mail, or text message communication.  


7.2 Al Communications Part of Record.  All communications with the Provider, regardless of form, may become a part of your medical records which may be produced to third parties in accordance with the law.

7.3 Acknowledgement Regarding E-mail Communication.  In authorizing the Practice to communicate with you by e-mail regarding your “protected health information” (PHI) using your e-mail address shown on the attached Schedule A, you acknowledge that:


7.3.1 E-mail is not a secure means for sending or receiving PHI and, in particular, if you send or receive e-mail through your employer’s email system, the employer may have the right to review it;


7.3.2 Although the Practice and the Provider will make reasonable efforts to keep e-mail communications confidential and secure, neither the Practice nor the Provider can assure or guarantee the confidentiality of e-mail communications;


7.3.3 In the discretion of the Provider, e-mail communications may be made a part of your permanent medical record; and


7.3.4 E-mail is not an appropriate means of communication regarding emergency or other time-sensitive issues or inquiries regarding sensitive information.


7.4 Unanswered/Delayed Responses to Communications.  If you do not receive a response to your e-mail message within one business day, you agree to use another means of communication to contact the Practice.  Neither the Practice nor its providers will be liable to you for any loss, cost, injury or expense caused by, or resulting from a delay in responding to you as a result of technical failures, including, but not limited to, (i) technical failures attributable to any internet service provider; (ii) power outages, failure of any electronic messaging software, failure to properly address e-mail messages; (iii) failure of the Practice’s computers or computer network, or faulty telephone or cable data transmission; (iv) any interception of e-mail communications by a third party; or (v) your failure to comply with the guidelines regarding use of e-mail communications in this paragraph.


Urgent, but non-emergency, medical questions or concerns should be communicated by telephone directly to the Practice.  If you are unable to reach the Practice by telephone, you agree to contact 911 immediately.



ARTICLE 8 – INSURANCE OR OTHER MEDICAL COVERAGE


8.1 Not Insurance.  This Agreement is not a substitute for health insurance or other health plan coverage (such as membership in an HMO, PPO, or POS).  This Agreement is not the purchase of insurance and is not enrollment in a health plan.  You agree that the Practice has advised you to purchase or keep in full force your health insurance policy(ies) or plans in order to cover you and your family members for healthcare costs not within the definition of Medical Services under this Agreement (or if this Agreement is terminated) and to prevent gaps in health coverage.


8.2 Referrals.  You understand and agree that from time to time, the Practice may order certain diagnostic/laboratory tests/point of care tests/injections that are not included in your membership or make referrals to a specialist.  The fees associated with those tests and evaluations by other providers are not covered and will not be reimbursed or credited in any way by the Practice.  You are responsible for arranging payment with those other providers directly.



ARTICLE 9 – OTHER TERMS


9.1 Assignability. You may not assign this Agreement or any rights you may have under it.  The Practice may assign this Agreement to an entity that purchases all of its assets or stock, or to another entity following an internal corporate reorganization.


9.2 Notices. All notices, requests, demands and other communications required or permitted under this Agreement must be in writing and delivered to the Practice at the address listed above.


9.3 Severability; Payment.  If for any reason any provision of this Agreement is deemed, by a court, to be legally invalid or unenforceable, the remainder of the Agreement is not affected.  The parties agree to modify the problematic provision to the minimum extent necessary to make it consistent with the law.  If for any reason the entire Agreement is held to be invalid, the Practice is entitled to a reasonable payment for the Services provided to you and your family members.


9.4 Legal Significance.  You acknowledge that this Agreement is a legal document and creates certain rights and responsibilities.  You also acknowledge that you have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.


9.5 Attached Schedules/Amendments. The attached Schedules A through D are incorporated into this Agreement.


9.6 Governing Law.  This Agreement is governed by the laws of the state of Florida.  All disputes not settled by arbitration must be resolved in the state or federal courts in or for Orange County, Florida.


9.7 Venue.  Venue for any arbitration or other legal proceeding lies in Orange County, Florida.  The parties waive any challenge to venue on any and all grounds including forum non conveniens.


9.8 Entire Agreement. This Agreement contains the entire understanding of the parties and supersedes all prior and contemporaneous agreements and understandings, inducements, or conditions, express or implied, oral or written, except as stated in the terms of this Agreement.


9.9 Amendment. This Agreement may not be modified or amended other than in writing and signed by all parties.


******** SIGNATURE PAGE TO FOLLOW ********


SECTION 624.27(4)(h), FLORIDA STATUTES, DISCLOSURE


THIS AGREEMENT IS NOT HEALTH INSURANCE AND THE PRIMARY CARE PROVIDER WILL NOT FILE ANY CLAIMS AGAINST THE PATIENT’S HEALTH INSURANCE POLICY OR PLAN FOR REIMBURSEMENT OF ANY PRIMARY CARE SERVICES COVERED BY THE AGREEMENT. THIS AGREEMENT DOES NOT QUALIFY AS MINIMUM ESSENTIAL COVERAGE TO SATISFY THE INDIVIDUAL SHARED RESPONSIBILITY PROVISION OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT, 26 U.S.C. S. 5000A. THIS AGREEMENT IS NOT WORKERS’ COMPENSATION INSURANCE AND DOES NOT REPLACE AN EMPLOYER’S OBLIGATIONS UNDER CHAPTER 440.


Attachments:

Schedule A:  Membership Enrollment Form

Schedule B:  Fee Schedule

Schedule C:  Menu of Services/Membership Benefits

Schedule D: Medicare Opt-Out Agreement/Member Signature

Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.

BOUTIQ MEDICAL CLINIC, LLC

PATIENT MEMBERSHIP AGREEMENT


This Membership Agreement is a contract for medical services to be provided by Boutiq Medical Clinic, LLC, and is effective as of the last date entered below.


Boutiq Medical Clinic, LLC (“Practice”), is a direct care practice, serving ages 7 and older, that currently aims to supplant the traditional insurance-based care model with conventional and innovative care delivery methods and services for a membership/subscription fee.


The Practice provides a range of family, pediatric, and other health services to its patients.


The Practice, is independently owned and operated, and employs different types of medical providers for the purpose of treating its patients.


The Practice is located at 1430 N. Mills avenue, Suite 120, Orlando, Florida 32803, and all office-based services are provided at that location.


The Practice’s regular hours are as follows:


Monday through Friday- 8am to 6pm

Saturday- 9am to 2pm

Sunday- Closed


At the Practice’s discretion, limited appointments may be made available on days and at times when it would normally be closed. Regular hours may vary.


During hours when the main office is closed, or during the business day, and when appropriate, the Practice may elect to provide virtual/telemedicine services to its patients.  No guarantee is made that these services will in fact be offered.


The terms “you” or “the Patient” refers to the patient whose signature appears on the signature page of this Agreement.  If the signature page or any schedule attached to this Agreement indicates that the term “you” or “the Patient” is intended to mean a couple or family (parents and children), then any references in this Agreement will mean each member of your family.


By signing this Agreement you are stating that you want to receive, in exchange for a fee, certain medical and non-medical services (collectively the "Services") from the Practice as part of your membership in the Practice.


The purpose of this Agreement is to define how and what Services will be furnished to you by the Practice.


ARTICLE 1 - PAYMENT


1.1 In exchange for the services provided for in this Agreement, you agree to pay the Practice the fees for the services you request as listed on the Fee List in Schedule B.


ARTICLE 2 - MEDICAL SERVICES


2.1 The Practice will provide you with the Services listed on the Menu of Services in Schedule C.  In this Agreement, the term Medical Services means the services that the Practice’s providers personally provide, as well as those services that staff members are permitted to provide at the direction or under supervision pursuant to the laws of the State of Florida.  Generally, Medical Services include health promotion, disease prevention, diagnosis, care, and treatment of patients during all stages of life.  Medical Services specifically include and exclude those items listed in Schedule C.


2.2 Alternate Provider.  Member understands that the Practice’s primary provider may be unavailable to provide services at times due to patient care obligations, illness, injury, vacation or other similar obligations.  During those particular times, the Practice will reasonably attempt to make arrangements to ensure another provider is able to assist you with your medical needs, or to be available via remote means of communication (i.e. through telemedicine).  The substitute provider may be, as permitted by law:  a substitute physician; nurse practitioner; registered nurse; physician assistant; or medical assistant.


2.3 Billing to Insurance Companies.  The Practice will provide the full range of services normally provided by a primary care physician in an office, via telemedicine, or in house call settings.  The Practice will not, even if covered by your primary insurance policy, bill those services to the insurance company or accept as payment in full, the reimbursement remitted by the insurer.  The Practice will, at its discretion, provide you with an explanation of the services provided by it so that you can seek reimbursement from your own insurer, if any.  The Practice will not communicate with the insurance company, nor will it change or modify its medical decision-making based on what your insurance company may, or may not, reimburse.



ARTICLE 3 - NON-MEDICAL SERVICES


3.1 24/7 Access; After Hours Care.  As a member of the Practice you will have direct access to the Practice’s providers via the patient portal (registration required by you) on a twenty-four hour per day, seven day per week basis for non-urgent matters. The Providers will respond as time permits. During the Provider's absence for vacations, continuing medical education, illness, emergencies, or normal days off, the Practice will be unavailable.  You acknowledge that the Practice’s providers may, from time to time, not be available at the times referred to above.


If at any time you experience an emergency medical situation that is life threatening or of a serious nature, you should NOT call or message the Practice but instead you should CALL 911 IMMEDIATELY.


3.2 Fax and E-Mail Access. You will be given the Practice’s fax number and e-mail address to which you can send non-urgent messages.  These communications will be handled by a staff member of the Practice in a timely manner, including a reasonably prompt response to you by the Provider or by the staff member.  E-mails will typically receive a response within twenty-four (24) hours.  If you do not receive a timely response, you should call the Practice directly or try an alternate means of communication.  In order to receive a response by e-mail or text message, you will be required to sign the Practice’s form outlining its policy on unsecured electronic communications. Again, all medical emergencies should be directed to 911, not the Practice.


3.3 Same Day/Next Day Appointments.  If you call or e-mail the Practice prior to noon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort will be made to schedule an appointment on the same day.  If you call or e-mail the Practice after noon on a normal office day to schedule an appointment, every reasonable effort will be made to schedule an appointment on the following day.  In any event, however, the Practice will make every reasonable effort to schedule an appointment for you on the same day that the request is made.  The Practice may satisfy its obligation to provide a prompt appointment under this section by scheduling a virtual/telemedicine visit with one of its providers if an in-office appointment is unavailable. The best way to schedule your appointment is via the website/patient portal or App. You may also walk in.


3.4 Hospital Visits.  Treatment in a hospital is not provided.  


3.5 Vaccines.  The Practice may, at your request, administer routine vaccinations when available.  The office visit for vaccine administration is covered by this Agreement, and is included in your membership fee.  However, the cost of the vaccine is not included.  Exact pricing for vaccinations is available upon request and will vary from time to time as suppliers adjust their pricing.



ARTICLE 4 – TERM AND TERMINATION


4.1 Term.  This Agreement will commence as of the date the last party signs it and will extend for one (1) year from that date.  Either party may terminate this Agreement at any time upon thirty (30) days written notice, however, no portion of the Enrollment Fee will be refundable.  However, if the Practice terminates this Agreement or stops providing direct care services, any monthly membership fees you paid in advance will be refunded to you as required by Florida law.


4.2 Renewal  This Agreement will automatically renew for additional one (1) year periods if neither you nor the Practice gives written notice that it does not want this Agreement to renew at least thirty (30) days prior to the current expiration date.  The Practice reserves the right to amend this Agreement on an annual basis to reflect certain operational changes and costs of operation.  The Practice will provide written notice of any change in terms as soon as reasonably practicable prior to the expiration date.  If Practice provides less than thirty (30) days’ notice of proposed changes, your obligation to provide thirty (30) days’ notice of intent not to renew is waived.  Should Practice provide appropriate notice of changes and you do not give timely notice that you do not want to renew, the Agreement will renew on the modified terms provided by the Practice.


4.2 The Practice may terminate your membership if you, or any member of your family, behave in an abusive or improper manner, or, if you fail to pay any fee or charge due for services.  In the event that the Practice exercises its right to terminate this Agreement for abusive or improper behavior or for failure to pay any fees or charges, the Practice is under no obligation to refund any portion of the Enrollment Fee or any Monthly Membership Fee, except those monthly membership fees you may have paid in advance.





ARTICLE 5 – NON-PARTICIPATION IN INSURANCE AND MEDICARE


5.1 Notice of Non-Participation Status.  As a direct care practice, the Practice does not participate in Medicare, Medicaid, Tricare, or any other government or private insurance plan.  As stated above, the Practice will not bill any services to an insurance company of any kind.


You acknowledge that the Practice does not participate in your health insurance, HMO, PPO, or POS plan or panel in any way and/or has OPTED OUT OF MEDICARE or is otherwise a NON-PARTICIPATING PROVIDER.  Neither the Practice nor its providers make any representation whatsoever that any fee for services provided by the Practice is covered by, or reimbursable by, your health insurance or by other third party discount or payment plans in which you or your family may be enrolled.  You will have the full and complete responsibility for any and all charges of the Practice not covered by your membership/subscription fee.  If you are eligible for Medicare, Medicaid, CHIP, or any other federal or state funded health plan, or become eligible during the term of this Agreement, then you agree to sign Schedule D.


5.2 Services Offered Are Not Insurance.  You understand and acknowledge that this Agreement does not provide health insurance coverage, including the minimal essential coverage required by applicable federal or state law.  It provides only the services described herein. It is recommended that health care insurance be obtained to cover medical services not provided for under this Agreement.



ARTICLE 6 – ARBITRATION


6.1 Arbitration of Disputes. In the event of any controversy or claim arising out of this Agreement, you agree that the dispute will be settled by submission to mandatory, confidential, and binding arbitration.  A copy of the Practice’s current arbitration policy is available upon request and incorporated into this section.  If not policy is in place, then arbitration will be before the American Health Lawyers Association’s Alternative Dispute Resolution Service employing its then-current arbitration rules.


ARTICLE 7 – COMMUNICATIONS


7.1 Unsecured Electronic Communication.  You acknowledge that communications with the Practice using fax, e-mail, and text are not guaranteed to be secure or confidential.  As such, you expressly waive the Practice’s obligation to ensure confidentiality with respect to unsolicited fax, e-mail, or text message communication.  


7.2 Al Communications Part of Record.  All communications with the Provider, regardless of form, may become a part of your medical records which may be produced to third parties in accordance with the law.

7.3 Acknowledgement Regarding E-mail Communication.  In authorizing the Practice to communicate with you by e-mail regarding your “protected health information” (PHI) using your e-mail address shown on the attached Schedule A, you acknowledge that:


7.3.1 E-mail is not a secure means for sending or receiving PHI and, in particular, if you send or receive e-mail through your employer’s email system, the employer may have the right to review it;


7.3.2 Although the Practice and the Provider will make reasonable efforts to keep e-mail communications confidential and secure, neither the Practice nor the Provider can assure or guarantee the confidentiality of e-mail communications;


7.3.3 In the discretion of the Provider, e-mail communications may be made a part of your permanent medical record; and


7.3.4 E-mail is not an appropriate means of communication regarding emergency or other time-sensitive issues or inquiries regarding sensitive information.


7.4 Unanswered/Delayed Responses to Communications.  If you do not receive a response to your e-mail message within one business day, you agree to use another means of communication to contact the Practice.  Neither the Practice nor its providers will be liable to you for any loss, cost, injury or expense caused by, or resulting from a delay in responding to you as a result of technical failures, including, but not limited to, (i) technical failures attributable to any internet service provider; (ii) power outages, failure of any electronic messaging software, failure to properly address e-mail messages; (iii) failure of the Practice’s computers or computer network, or faulty telephone or cable data transmission; (iv) any interception of e-mail communications by a third party; or (v) your failure to comply with the guidelines regarding use of e-mail communications in this paragraph.


Urgent, but non-emergency, medical questions or concerns should be communicated by telephone directly to the Practice.  If you are unable to reach the Practice by telephone, you agree to contact 911 immediately.



ARTICLE 8 – INSURANCE OR OTHER MEDICAL COVERAGE


8.1 Not Insurance.  This Agreement is not a substitute for health insurance or other health plan coverage (such as membership in an HMO, PPO, or POS).  This Agreement is not the purchase of insurance and is not enrollment in a health plan.  You agree that the Practice has advised you to purchase or keep in full force your health insurance policy(ies) or plans in order to cover you and your family members for healthcare costs not within the definition of Medical Services under this Agreement (or if this Agreement is terminated) and to prevent gaps in health coverage.


8.2 Referrals.  You understand and agree that from time to time, the Practice may order certain diagnostic/laboratory tests/point of care tests/injections that are not included in your membership or make referrals to a specialist.  The fees associated with those tests and evaluations by other providers are not covered and will not be reimbursed or credited in any way by the Practice.  You are responsible for arranging payment with those other providers directly.



ARTICLE 9 – OTHER TERMS


9.1 Assignability. You may not assign this Agreement or any rights you may have under it.  The Practice may assign this Agreement to an entity that purchases all of its assets or stock, or to another entity following an internal corporate reorganization.


9.2 Notices. All notices, requests, demands and other communications required or permitted under this Agreement must be in writing and delivered to the Practice at the address listed above.


9.3 Severability; Payment.  If for any reason any provision of this Agreement is deemed, by a court, to be legally invalid or unenforceable, the remainder of the Agreement is not affected.  The parties agree to modify the problematic provision to the minimum extent necessary to make it consistent with the law.  If for any reason the entire Agreement is held to be invalid, the Practice is entitled to a reasonable payment for the Services provided to you and your family members.


9.4 Legal Significance.  You acknowledge that this Agreement is a legal document and creates certain rights and responsibilities.  You also acknowledge that you have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.


9.5 Attached Schedules/Amendments. The attached Schedules A through D are incorporated into this Agreement.


9.6 Governing Law.  This Agreement is governed by the laws of the state of Florida.  All disputes not settled by arbitration must be resolved in the state or federal courts in or for Orange County, Florida.


9.7 Venue.  Venue for any arbitration or other legal proceeding lies in Orange County, Florida.  The parties waive any challenge to venue on any and all grounds including forum non conveniens.


9.8 Entire Agreement. This Agreement contains the entire understanding of the parties and supersedes all prior and contemporaneous agreements and understandings, inducements, or conditions, express or implied, oral or written, except as stated in the terms of this Agreement.


9.9 Amendment. This Agreement may not be modified or amended other than in writing and signed by all parties.


******** SIGNATURE PAGE TO FOLLOW ********


SECTION 624.27(4)(h), FLORIDA STATUTES, DISCLOSURE


THIS AGREEMENT IS NOT HEALTH INSURANCE AND THE PRIMARY CARE PROVIDER WILL NOT FILE ANY CLAIMS AGAINST THE PATIENT’S HEALTH INSURANCE POLICY OR PLAN FOR REIMBURSEMENT OF ANY PRIMARY CARE SERVICES COVERED BY THE AGREEMENT. THIS AGREEMENT DOES NOT QUALIFY AS MINIMUM ESSENTIAL COVERAGE TO SATISFY THE INDIVIDUAL SHARED RESPONSIBILITY PROVISION OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT, 26 U.S.C. S. 5000A. THIS AGREEMENT IS NOT WORKERS’ COMPENSATION INSURANCE AND DOES NOT REPLACE AN EMPLOYER’S OBLIGATIONS UNDER CHAPTER 440.


Attachments:

Schedule A:  Membership Enrollment Form

Schedule B:  Fee Schedule

Schedule C:  Menu of Services/Membership Benefits

Schedule D: Medicare Opt-Out Agreement/Member Signature

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BOUTIQ MEDICAL CLINIC, LLC

PATIENT MEMBERSHIP AGREEMENT


This Membership Agreement is a contract for medical services to be provided by Boutiq Medical Clinic, LLC, and is effective as of the last date entered below.


Boutiq Medical Clinic, LLC (“Practice”), is a direct care practice, serving ages 7 and older, that currently aims to supplant the traditional insurance-based care model with conventional and innovative care delivery methods and services for a membership/subscription fee.


The Practice provides a range of family, pediatric, and other health services to its patients.


The Practice, is independently owned and operated, and employs different types of medical providers for the purpose of treating its patients.


The Practice is located at 1430 N. Mills avenue, Suite 120, Orlando, Florida 32803, and all office-based services are provided at that location.


The Practice’s regular hours are as follows:


Monday through Friday- 8am to 6pm

Saturday- 9am to 2pm

Sunday- Closed


At the Practice’s discretion, limited appointments may be made available on days and at times when it would normally be closed. Regular hours may vary.


During hours when the main office is closed, or during the business day, and when appropriate, the Practice may elect to provide virtual/telemedicine services to its patients.  No guarantee is made that these services will in fact be offered.


The terms “you” or “the Patient” refers to the patient whose signature appears on the signature page of this Agreement.  If the signature page or any schedule attached to this Agreement indicates that the term “you” or “the Patient” is intended to mean a couple or family (parents and children), then any references in this Agreement will mean each member of your family.


By signing this Agreement you are stating that you want to receive, in exchange for a fee, certain medical and non-medical services (collectively the "Services") from the Practice as part of your membership in the Practice.


The purpose of this Agreement is to define how and what Services will be furnished to you by the Practice.


ARTICLE 1 - PAYMENT


1.1 In exchange for the services provided for in this Agreement, you agree to pay the Practice the fees for the services you request as listed on the Fee List in Schedule B.


ARTICLE 2 - MEDICAL SERVICES


2.1 The Practice will provide you with the Services listed on the Menu of Services in Schedule C.  In this Agreement, the term Medical Services means the services that the Practice’s providers personally provide, as well as those services that staff members are permitted to provide at the direction or under supervision pursuant to the laws of the State of Florida.  Generally, Medical Services include health promotion, disease prevention, diagnosis, care, and treatment of patients during all stages of life.  Medical Services specifically include and exclude those items listed in Schedule C.


2.2 Alternate Provider.  Member understands that the Practice’s primary provider may be unavailable to provide services at times due to patient care obligations, illness, injury, vacation or other similar obligations.  During those particular times, the Practice will reasonably attempt to make arrangements to ensure another provider is able to assist you with your medical needs, or to be available via remote means of communication (i.e. through telemedicine).  The substitute provider may be, as permitted by law:  a substitute physician; nurse practitioner; registered nurse; physician assistant; or medical assistant.


2.3 Billing to Insurance Companies.  The Practice will provide the full range of services normally provided by a primary care physician in an office, via telemedicine, or in house call settings.  The Practice will not, even if covered by your primary insurance policy, bill those services to the insurance company or accept as payment in full, the reimbursement remitted by the insurer.  The Practice will, at its discretion, provide you with an explanation of the services provided by it so that you can seek reimbursement from your own insurer, if any.  The Practice will not communicate with the insurance company, nor will it change or modify its medical decision-making based on what your insurance company may, or may not, reimburse.



ARTICLE 3 - NON-MEDICAL SERVICES


3.1 24/7 Access; After Hours Care.  As a member of the Practice you will have direct access to the Practice’s providers via the patient portal (registration required by you) on a twenty-four hour per day, seven day per week basis for non-urgent matters. The Providers will respond as time permits. During the Provider's absence for vacations, continuing medical education, illness, emergencies, or normal days off, the Practice will be unavailable.  You acknowledge that the Practice’s providers may, from time to time, not be available at the times referred to above.


If at any time you experience an emergency medical situation that is life threatening or of a serious nature, you should NOT call or message the Practice but instead you should CALL 911 IMMEDIATELY.


3.2 Fax and E-Mail Access. You will be given the Practice’s fax number and e-mail address to which you can send non-urgent messages.  These communications will be handled by a staff member of the Practice in a timely manner, including a reasonably prompt response to you by the Provider or by the staff member.  E-mails will typically receive a response within twenty-four (24) hours.  If you do not receive a timely response, you should call the Practice directly or try an alternate means of communication.  In order to receive a response by e-mail or text message, you will be required to sign the Practice’s form outlining its policy on unsecured electronic communications. Again, all medical emergencies should be directed to 911, not the Practice.


3.3 Same Day/Next Day Appointments.  If you call or e-mail the Practice prior to noon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort will be made to schedule an appointment on the same day.  If you call or e-mail the Practice after noon on a normal office day to schedule an appointment, every reasonable effort will be made to schedule an appointment on the following day.  In any event, however, the Practice will make every reasonable effort to schedule an appointment for you on the same day that the request is made.  The Practice may satisfy its obligation to provide a prompt appointment under this section by scheduling a virtual/telemedicine visit with one of its providers if an in-office appointment is unavailable. The best way to schedule your appointment is via the website/patient portal or App. You may also walk in.


3.4 Hospital Visits.  Treatment in a hospital is not provided.  


3.5 Vaccines.  The Practice may, at your request, administer routine vaccinations when available.  The office visit for vaccine administration is covered by this Agreement, and is included in your membership fee.  However, the cost of the vaccine is not included.  Exact pricing for vaccinations is available upon request and will vary from time to time as suppliers adjust their pricing.



ARTICLE 4 – TERM AND TERMINATION


4.1 Term.  This Agreement will commence as of the date the last party signs it and will extend for one (1) year from that date.  Either party may terminate this Agreement at any time upon thirty (30) days written notice, however, no portion of the Enrollment Fee will be refundable.  However, if the Practice terminates this Agreement or stops providing direct care services, any monthly membership fees you paid in advance will be refunded to you as required by Florida law.


4.2 Renewal  This Agreement will automatically renew for additional one (1) year periods if neither you nor the Practice gives written notice that it does not want this Agreement to renew at least thirty (30) days prior to the current expiration date.  The Practice reserves the right to amend this Agreement on an annual basis to reflect certain operational changes and costs of operation.  The Practice will provide written notice of any change in terms as soon as reasonably practicable prior to the expiration date.  If Practice provides less than thirty (30) days’ notice of proposed changes, your obligation to provide thirty (30) days’ notice of intent not to renew is waived.  Should Practice provide appropriate notice of changes and you do not give timely notice that you do not want to renew, the Agreement will renew on the modified terms provided by the Practice.


4.2 The Practice may terminate your membership if you, or any member of your family, behave in an abusive or improper manner, or, if you fail to pay any fee or charge due for services.  In the event that the Practice exercises its right to terminate this Agreement for abusive or improper behavior or for failure to pay any fees or charges, the Practice is under no obligation to refund any portion of the Enrollment Fee or any Monthly Membership Fee, except those monthly membership fees you may have paid in advance.





ARTICLE 5 – NON-PARTICIPATION IN INSURANCE AND MEDICARE


5.1 Notice of Non-Participation Status.  As a direct care practice, the Practice does not participate in Medicare, Medicaid, Tricare, or any other government or private insurance plan.  As stated above, the Practice will not bill any services to an insurance company of any kind.


You acknowledge that the Practice does not participate in your health insurance, HMO, PPO, or POS plan or panel in any way and/or has OPTED OUT OF MEDICARE or is otherwise a NON-PARTICIPATING PROVIDER.  Neither the Practice nor its providers make any representation whatsoever that any fee for services provided by the Practice is covered by, or reimbursable by, your health insurance or by other third party discount or payment plans in which you or your family may be enrolled.  You will have the full and complete responsibility for any and all charges of the Practice not covered by your membership/subscription fee.  If you are eligible for Medicare, Medicaid, CHIP, or any other federal or state funded health plan, or become eligible during the term of this Agreement, then you agree to sign Schedule D.


5.2 Services Offered Are Not Insurance.  You understand and acknowledge that this Agreement does not provide health insurance coverage, including the minimal essential coverage required by applicable federal or state law.  It provides only the services described herein. It is recommended that health care insurance be obtained to cover medical services not provided for under this Agreement.



ARTICLE 6 – ARBITRATION


6.1 Arbitration of Disputes. In the event of any controversy or claim arising out of this Agreement, you agree that the dispute will be settled by submission to mandatory, confidential, and binding arbitration.  A copy of the Practice’s current arbitration policy is available upon request and incorporated into this section.  If not policy is in place, then arbitration will be before the American Health Lawyers Association’s Alternative Dispute Resolution Service employing its then-current arbitration rules.


ARTICLE 7 – COMMUNICATIONS


7.1 Unsecured Electronic Communication.  You acknowledge that communications with the Practice using fax, e-mail, and text are not guaranteed to be secure or confidential.  As such, you expressly waive the Practice’s obligation to ensure confidentiality with respect to unsolicited fax, e-mail, or text message communication.  


7.2 Al Communications Part of Record.  All communications with the Provider, regardless of form, may become a part of your medical records which may be produced to third parties in accordance with the law.

7.3 Acknowledgement Regarding E-mail Communication.  In authorizing the Practice to communicate with you by e-mail regarding your “protected health information” (PHI) using your e-mail address shown on the attached Schedule A, you acknowledge that:


7.3.1 E-mail is not a secure means for sending or receiving PHI and, in particular, if you send or receive e-mail through your employer’s email system, the employer may have the right to review it;


7.3.2 Although the Practice and the Provider will make reasonable efforts to keep e-mail communications confidential and secure, neither the Practice nor the Provider can assure or guarantee the confidentiality of e-mail communications;


7.3.3 In the discretion of the Provider, e-mail communications may be made a part of your permanent medical record; and


7.3.4 E-mail is not an appropriate means of communication regarding emergency or other time-sensitive issues or inquiries regarding sensitive information.


7.4 Unanswered/Delayed Responses to Communications.  If you do not receive a response to your e-mail message within one business day, you agree to use another means of communication to contact the Practice.  Neither the Practice nor its providers will be liable to you for any loss, cost, injury or expense caused by, or resulting from a delay in responding to you as a result of technical failures, including, but not limited to, (i) technical failures attributable to any internet service provider; (ii) power outages, failure of any electronic messaging software, failure to properly address e-mail messages; (iii) failure of the Practice’s computers or computer network, or faulty telephone or cable data transmission; (iv) any interception of e-mail communications by a third party; or (v) your failure to comply with the guidelines regarding use of e-mail communications in this paragraph.


Urgent, but non-emergency, medical questions or concerns should be communicated by telephone directly to the Practice.  If you are unable to reach the Practice by telephone, you agree to contact 911 immediately.



ARTICLE 8 – INSURANCE OR OTHER MEDICAL COVERAGE


8.1 Not Insurance.  This Agreement is not a substitute for health insurance or other health plan coverage (such as membership in an HMO, PPO, or POS).  This Agreement is not the purchase of insurance and is not enrollment in a health plan.  You agree that the Practice has advised you to purchase or keep in full force your health insurance policy(ies) or plans in order to cover you and your family members for healthcare costs not within the definition of Medical Services under this Agreement (or if this Agreement is terminated) and to prevent gaps in health coverage.


8.2 Referrals.  You understand and agree that from time to time, the Practice may order certain diagnostic/laboratory tests/point of care tests/injections that are not included in your membership or make referrals to a specialist.  The fees associated with those tests and evaluations by other providers are not covered and will not be reimbursed or credited in any way by the Practice.  You are responsible for arranging payment with those other providers directly.



ARTICLE 9 – OTHER TERMS


9.1 Assignability. You may not assign this Agreement or any rights you may have under it.  The Practice may assign this Agreement to an entity that purchases all of its assets or stock, or to another entity following an internal corporate reorganization.


9.2 Notices. All notices, requests, demands and other communications required or permitted under this Agreement must be in writing and delivered to the Practice at the address listed above.


9.3 Severability; Payment.  If for any reason any provision of this Agreement is deemed, by a court, to be legally invalid or unenforceable, the remainder of the Agreement is not affected.  The parties agree to modify the problematic provision to the minimum extent necessary to make it consistent with the law.  If for any reason the entire Agreement is held to be invalid, the Practice is entitled to a reasonable payment for the Services provided to you and your family members.


9.4 Legal Significance.  You acknowledge that this Agreement is a legal document and creates certain rights and responsibilities.  You also acknowledge that you have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.


9.5 Attached Schedules/Amendments. The attached Schedules A through D are incorporated into this Agreement.


9.6 Governing Law.  This Agreement is governed by the laws of the state of Florida.  All disputes not settled by arbitration must be resolved in the state or federal courts in or for Orange County, Florida.


9.7 Venue.  Venue for any arbitration or other legal proceeding lies in Orange County, Florida.  The parties waive any challenge to venue on any and all grounds including forum non conveniens.


9.8 Entire Agreement. This Agreement contains the entire understanding of the parties and supersedes all prior and contemporaneous agreements and understandings, inducements, or conditions, express or implied, oral or written, except as stated in the terms of this Agreement.


9.9 Amendment. This Agreement may not be modified or amended other than in writing and signed by all parties.


******** SIGNATURE PAGE TO FOLLOW ********


SECTION 624.27(4)(h), FLORIDA STATUTES, DISCLOSURE


THIS AGREEMENT IS NOT HEALTH INSURANCE AND THE PRIMARY CARE PROVIDER WILL NOT FILE ANY CLAIMS AGAINST THE PATIENT’S HEALTH INSURANCE POLICY OR PLAN FOR REIMBURSEMENT OF ANY PRIMARY CARE SERVICES COVERED BY THE AGREEMENT. THIS AGREEMENT DOES NOT QUALIFY AS MINIMUM ESSENTIAL COVERAGE TO SATISFY THE INDIVIDUAL SHARED RESPONSIBILITY PROVISION OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT, 26 U.S.C. S. 5000A. THIS AGREEMENT IS NOT WORKERS’ COMPENSATION INSURANCE AND DOES NOT REPLACE AN EMPLOYER’S OBLIGATIONS UNDER CHAPTER 440.


Attachments:

Schedule A:  Membership Enrollment Form

Schedule B:  Fee Schedule

Schedule C:  Menu of Services/Membership Benefits

Schedule D: Medicare Opt-Out Agreement/Member Signature

Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.