Membership Agreement

This is an Agreement between Dunes Family Clinic, LLC (Practice), a State of Indiana LLC, Dr. Juana Ambriz de Williams, DNP, FNP-BC (Nurse Practitioner), in her capacity as an agent of Dunes Family Clinic LLC and you, (Patient).   

The Nurse Practitioner, is board certified in family practice, delivers care on behalf of Practice in Valparaiso, Indiana. In exchange for certain fees paid by You, Practice, through its Nurse Practitioner(s), agrees to provide Patient with the Services described in this Agreement on the terms and conditions set forth in this Agreement. The practice website is www.dunesfamilyclinic.com.   

1. Patient. 

A patient is defined as those persons for whom the Nurse Practitioner shall provide Services, and who are signatories to, or listed on the documents attached as Appendix 1, and incorporated by reference, to this agreement.  

2. Services. As used in this Agreement, the term Services shall mean a package of ongoing primary care services, both medical and non-medical, and certain amenities (collectively “Services”) , which are offered by Practice, and set forth in Appendix 1 and 2. The Patient will be provided with methods to contact the Nurse Practitioner via phone, email, and other methods of electronic communication. Nurse Practitioner will make every effort to address the needs of the Patient in a timely manner, but cannot guarantee availability, and cannot guarantee that the patient will not need to seek treatment in the urgent care or emergency department setting. 

2.1 Consent to Treat.  You acknowledge and hereby authorize Practice to use and/or disclose Your health information which specifically identifies You, or which can reasonably be used to identify You, to carry out Your treatment, payment and healthcare operations.  Treatment includes but is not limited to: the administration and performance of all treatments, the administration of any needed anesthetics, the administration and use of prescribed medication, the performance of such procedures as may be deemed necessary or advisable in the treatment of the member, including but not limited to: diagnostic procedures, the taking and utilization of cultures and of other medically accepted laboratory tests, all of which in the judgment of the attending nurse practitioner or their assigned designees may be considered medically necessary or advisable. 

3. Fees.  In exchange for the services described herein, Patient agrees to pay Practice, the amount as set forth in Appendix 1 and 2, attached. Applicable enrollment fees are payable upon execution of this agreement. If this Agreement is terminated by either party before the end of an applicable annual period, then the Practice may seek full payment for the remaining period of service based on the membership fee and the itemized charges, set forth in Appendix 2, for services rendered to Patient up to the date of termination.     

4. Non-Participation in Insurance. Patient acknowledges that neither Practice, nor the Nurse Practitioners may bill any health insurance or HMO plans for services provided under this agreement. Neither the Practice nor Nurse Practitioners make any representations regarding third party insurance reimbursement of fees paid under this Agreement. The Patient shall retain full and complete responsibility for any such determination. The Practice will not bill an insurance company for services for a Patient paying a membership fee.

5. Insurance or Other Medical Coverage. Patient acknowledges and understands that this Agreement is not an insurance plan, and not a substitute for health insurance or other health plan coverage (such as membership in an HMO). It will not cover hospital services, or any services not personally provided by Practice, or its Nurse Practitioners. Patient acknowledges that Practice has advised that patient obtain or keep in full force such health insurance policy(ies) or plans that will cover Patient for general healthcare costs. Patient acknowledges that THIS AGREEMENT IS NOT A CONTRACT THAT PROVIDES HEALTH INSURANCE, in isolation does NOT meet the insurance requirements of the Affordable Care Act, and is not intended to replace any existing or future health insurance or health plan coverage that Patient may carry. This Agreement is for ongoing primary care, and the Patient may need to visit the emergency room or urgent care from time to time. Nurse Practitioner will make every effort to be available at all times via phone, email, other methods such as “after hours” appointments when appropriate, but Nurse Practitioner cannot guarantee 24/7 availability.  

6. Term.  This Agreement will commence on the date it is signed by the Patient and Nurse Practitioner below and will extend annually thereafter. Notwithstanding the above, both Patient and Practice shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination. The Patient may terminate the agreement with forty-eight hours prior notice, but the Practice shall give thirty days prior written notice to the Patient and shall provide the patient with a list of other Practices in the community in a manner consistent with local patient abandonment laws. Unless previously terminated as set forth above, at the expiration of the initial one-year term (and each succeeding annual term), the Agreement will automatically renew for successive annual terms upon the payment of the periodic fee or installment at the beginning of the contract year. Examples of reasons the Practice may wish to terminate the agreement with the Patient may include but are not limited to: 

(a)  The Patient fails to pay applicable fees owed pursuant to Appendix 1 and 2 per this Agreement;   

(b)  The Patient has performed an act that constitutes fraud;   

(c)  The Patient repeatedly fails to adhere to the recommended treatment plan, especially  regarding the use of controlled substances;   

(d)  The Patient is abusive, or presents an emotional or physical danger to the staff or other  patients of Practice;   

(e)  Practice discontinues operation; and   

(f)  Practice has a right to determine whom to accept as a patient, just as a patient has the right  to choose his or her Nurse Practitioner. Practice may also terminate a patient without cause as long as the termination is handled appropriately (without violating patient abandonment laws).   

7. Privacy & Communications. You acknowledge that communications with the Nurse Practitioner using e-mail, facsimile, video chat, instant messaging, and cell phone are not guaranteed to be secure or confidential methods of communications. The practice will make an effort to secure all communications via passwords and other protective means and these will be discussed in an annually updated Health Insurance Portability and Accountability Act (HIPAA) “Risk Assessment.” The practice will make an effort to promote the utilization of the most secure methods of communication, such as software platforms with data encryption, HIPAA familiarity, and a willingness to sign HIPAA Business Associate Agreements. This may mean that conversations over certain communication platforms are highlighted as preferable based on higher levels of data encryption, but many communication platforms, including email, may be made available to the patient. If the Patient initiates a conversation in which the Patient discloses “Protected Health Information (PHI)” on one or more of these communication platforms then the Patient has authorized the Practice to communicate with the Patient regarding PHI in the same format.  

8. Severability. If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of the Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable.  

9. Reimbursement for Services if Agreement is Invalidated. If this Agreement is held to be invalid for any reason, and if Practice is therefore required to refund all or any portion of the periodic fees paid by Patient, Patient agrees to pay Practice an amount equal to the fair market value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid.  

10. Assignment. This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient.  

11. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Indiana and all disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for the Practice address in Valparaiso, Indiana.  

12. Patient Understandings:  

_____ This Agreement is for ongoing primary care and is NOT a medical insurance agreement.  

_____ I do NOT have an emergent medical problem at this time.
 

_____ In the event of a medical emergency, I agree to call 911 first.
 

_____ I do NOT expect the practice to file or fight any third party insurance claims on my behalf.  

_____ I do NOT expect the practice to prescribe chronic controlled substances on my behalf. (These include commonly abused opioid medications, benzodiazepines, and stimulants.)  

_____ In the event I have a complaint about the Practice, I will first notify the Practice directly.  

_____ This Agreement (without a “wrap around” compliant insurance policy) does not meet the individual insurance requirement of the Affordable Care Act.
 

_____ I am enrolling (myself and my family if applicable) in the practice voluntarily.
 

_____ I may receive a copy of this document upon request.
 

_____ This Agreement is non-transferable.   

This Agreement is for ongoing primary care. This is Agreement is NOT HEALTH INSURANCE and is NOT A HEALTH MAINTENANCE ORGANIZATION. The Patient may need to use the care of specialists, emergency rooms, and urgent care centers that are outside the scope of this Agreement. Each Nurse Practitioner within the Practice will make an appropriate determination about the scope of primary care services offered by the Nurse Practitioner. Examples of common conditions we treat, procedures we perform, and medications we prescribe are listed on our website and are subject to change.  

Fee Schedule 

Enrollment Fee: This is charged when the Patient enrolls with the Practice and is nonrefundable. This fee is subject to change. If a patient discontinues membership and wishes to re-enroll in the practice we reserve the right to decline re-enrollment or to require that the re-enrollment fee reflect an amount equivalent to the time of absent payments when dis-enrolled from the Practice. 

Your Enrollment fee is $125. 

Re-enrollment Fee: Requests to restart memberships are subject to approval and availability. If accepted, a minimum re-enrollment fee of $500 per person will apply before service can be restarted. 

Annual Periodic Fee: (billed at the beginning of the service period) – This fee is for ongoing primary care services. Unlimited scheduled in person visits per year are available to you at no additional cost. Your number of virtual visits (e-mail, electronic, phone) is not capped. We prefer that you schedule visits more than 24 hours in advance when possible. Some ancillary services will be passed through “at cost” (up to 10% markup to cover transaction costs). Examples of these ancillary services include laboratory testing, radiologic testing, and dispensed medications and these are described in Appendix B. Many services available in our office (such as EKGs) are available at no additional cost to you. Items available at no additional cost will be listed on our website and are subject to change. 

The annual periodic fee is $900 per year for adults and $300 per year for children under 20 years old. The annual periodic fee is $2100 for two adults and their dependent children under 20 years old. The annual fee is due at the beginning of the membership and may be paid in installments. 

After-Hours Visits 

There is no guarantee of after-hours availability. This agreement is for ongoing primary care, not emergency or urgent care. Your Nurse Practitioner will make reasonable efforts to see you as needed after hours if your Nurse Practitioner is available.  

Acceptance of Patients 

We reserve the right to accept or decline patients based upon our capability to appropriately handle the patient’s primary care needs. We may decline new patients pursuant to the guidelines proffered in Section 6 (Term), because the Nurse Practitioner’s panel of patients is full (capped at 1,200 patients or fewer), or because the patient requires medical care not within the Nurse Practitioner’s scope of services.   

Ongoing Primary Care is included with the Periodic Fee described in Appendix 1. Please see a list of some of the chronic conditions we routinely treat on the Practice website (subject to change). There are no itemized fees for office visits.  

In-Office Procedures we are generally comfortable performing are listed on the Practice website. These are typically available at no additional cost unless otherwise designated, and these are also subject to change.  

Laboratory Studies will be drawn in the office at no additional charge and the Patient will be charged according to the direct price rate we have negotiated with the lab. An example of common laboratory studies and their prices (subject to change) are listed on the practice website.  

Medications will be ordered in the most cost effective manner possible for the Patient. When we dispense medications in the office these medications will be made available to the patient at wholesale cost. Examples of commonly dispensed medications and their prices (subject to change) are listed on the practice website.  

Pathology studies (most commonly skin biopsies) will be ordered in the most economical manner possible. Anticipated prices for these studies (subject to change) are listed on the Practice website. 

Radiology studies will be ordered in the most cost effective manner possible for the Patient. Commonly ordered radiologic studies and prices (subject to change) are listed on the website.  

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

Vaccinations are NOT offered in our office at this time due to the cost prohibitive nature of stocking a limited supply. We will make an effort to help you obtain needed vaccinations elsewhere in the most cost effective manner possible.  

Hospital Services are NOT covered by our membership plan. If you need to be hospitalized, you will be under the care of a Hospitalist. We will work collaboratively with your Hospitalist and coordinate your care following discharge from the hospital.