Terms of Service

Background

Axis Arthritis and Rheumatology Care, PLLC (“the Practice,” “we,” “us,” or “our”), is a virtual, direct-pay, arthritis and rheumatology clinic, which delivers services to its patients in an insurance-free, cash-pay, practice model. This document describes the terms and conditions, or Terms of Service (TOS) governing the medical care to be delivered to You by the Practice.

Definitions

Services. In this Agreement, “Services” means the collection of services, medical and non-medical, which are described in Appendix A (attached and incorporated by reference), which the Practice agrees to provide to the Member under the terms and conditions of this Agreement.
Patient. In this Agreement, “Patient,” “Member,” “You,” or “Yours” means the persons for whom the Practice shall provide care, who have signed this Agreement, and/or whose names appear in appendix B (attached and incorporated by reference)

Agreement

3. Payments – Amounts and Methods.

(a) In exchange for the Services described in Appendix A, the Member agrees to pay the amount as described in Appendix C ( attached and incorporated by reference);

(b) Upon Executing this Agreement, the Patient shall schedule, and remit payment for the initial consultation, which shall be forfeited, in the event that Patient cancels the initial consultation without at least 24 hours’ notice.

4. Non-Participation in Insurance. As a direct-pay practice, We do not participate in any health plans, HMOs, or other third-party payors, whether private or government sponsored and are prohibited from submitting charges to such payors. Therefore, both Patient and physician agree that they shall not submit charges or seek reimbursement from any third-party payor.

5. Medicare. We cannot accept Medicare beneficiaries into the Practice. The law prohibits Physicians from privately contracting with patients who are Medicare beneficiaries or Medicare eligible. The Patient understands that the Practice physician is not yet fully opted out of Medicare and so may not accept Medicare beneficiaries into the practice. Accordingly, You cerify that You are neither a beneficiary of, nor eligible for, Medicare. Furthermore, You agree that if You are, or become eligible for Medicare during the term of this Agreement, You shall immediately inform the Practice, and the Agreement shall be terminated in compliance with patient abandonment regulations.

6. Medicaid. The Practice is not enrolled with, and does not participate in , any Medicaid plans so may not submit billing or seek reimbursement from Medicaid for Services provided under this Agreement. Patients who are Medicaid beneficiaries understand that they are joining this Practice under private contract, and not as Medicaid beneficiaries. Accordingly, neither the Patient, nor the Practice shall submit charges or seek reimbursement from Medicaid for services provided by the Practice.

7. Electronic Communications. While the Practice endeavors to provide Patients with the convenience of a wide variety of electronic communication options, We are careful to comply with confidentiality requirements and take our duty to protect patient privacy seriously. However, communications by email, facsimile, video chat, cell phone, texting, and other electronic means, can never be guaranteed to be 100% secure or confidential. Therefore, the Patient understands and agrees that by initialing this clause where indicated or agreeing to participate in any of the above means of communication, the Patient expressly waives any guarantee of absolute confidentiality with respect to their use. The Patient further understands that participation in any of the above means of communication is not a condition of membership in this Practice, and that the Patient has the option to decline any particular method of communication.

8. Email and Text Usage. By providing an email address where requested in Appendix B, You authorize the Practice and its staff to communicate with You by email and/or patient portal regarding the Patient’s “protected health information” (PHI). Likewise, in providing a cell phone number where indicated in Appendix B and checking the “YES” box on the

“As that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulations.”

corresponding consent question, You agree to participate in text message communication containing PHI through the cell number provided. You further understand and acknowledge that:

(a) Email, text messaging and other electronic means of communication are not necessarily secure methods of sending or receiving PHI, and there is always a possibility that a third party may gain access;

(b) Email, text messaging and other electronic and other electronic messaging, are not appropriate means of communication in an emergency, for dealing with time-sensitive issues, or for disclosing sensitive information. In an emergency or a situation that could reasonably be expected to develop into an emergency, You understand and agree to call 911 or go to the nearest emergency room and follow the instructions of emergency personnel. ___ Initial

9. Technical Failure. Neither the Practice nor its staff will be liable for any loss, injury, or expense arising from a delay in responding to the Patient when that delay is caused by technical failure. Examples of technical failures: (i) failures caused by an internet or cell phone service provider; (ii) power outages; (iii) failure of electronic messaging software or email provider; (iv) failure of the Practice’s computers or computer network, or faulty telephone or cable data transmission; (iv) any interception of email communications by a third party which is unauthorized by the Practice; or (v) Patient’s failure to comply with the guidelines for use of email or text messaging, as described in this Agreement.

10. Physician Absence. From time to time, due to circumstances such as conferences, patient emergencies, physician illness, and vacations, the physician may be temporarily unavailable. When the date/s of such absences are known in advance, the Practice shall notify the Patient so that they may schedule non-urgent care accordingly. In the event of unexpected physician absence, Patients with scheduled appointments shall be notified as soon as practicable, and appointments shall be rescheduled at the Patient’s convenience. If, during a Physician’s absence, the Patient should experience an acute medical issue requiring immediate attention, the Patient understands and agrees to proceed to an urgent care facility, emergency department, as is appropriate, for immediate medical treatment. Charges from such outside facilities and providers are the Patient’s responsibility and are not included in this Membership Agreement. Notwithstanding the above, the Patient’s insurance plan, if any, may reimburse all or a portion of such charges.

11. No Surprise Act Notice. You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who do not have insurance or who are not using insurance an estimate of the cost of medical items and services provided to them. You are entitled to receive an estimate of the total expected cost of any non-emergency items or services, including related costs like medical tests, prescription drugs, equipment, and hospital fees. If needed, You should ask your health care provider to give you a Good Faith Estimate in writing at least one business day before your scheduled medical service or item. You can also ask your provider for a Good Faith Estimate before you schedule an appointment or service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises, or call the number on our website for more information.

12. Dispute Resolution. Each party agrees not to make any inaccurate or untrue and disparaging statements, oral, written, or electronic, about the other. The Practice strives to deliver only the best of personalized care to every Patient, but occasionally misunderstandings arise. We welcome sincere and open dialogue with our patients, especially if we fail to meet expectations, and We are committed to resolving all Patient concerns.

Therefore, if a Patient is dissatisfied with, or has concerns about, any staff member, service, treatment, or experience arising from their membership in this Practice, the Patient and the Practice agree to refrain from making, posting, or causing to be posted on the internet or any social media, any untrue, unconfirmed, inaccurate, disparaging comments about the other. Rather, the parties agree to engage in the following process:

(a) The Patient shall first discuss any complaints, concerns, or issues with their physician;
(b) The physician shall respond to each of the Patient’s concerns, and;

(c) If, after such a response, the Patient remains dissatisfied, the parties shall enter into discussion and attempt to reach a mutually acceptable solution.

13. Notice. Notice as required under this TOS, may be achieved either through electronic means at the email address provided by the party to be noticed or through first-class US Mail, to the Practice, at the address first written above and to the Patient at the address provided in Appendix B or the most recent address contained in the Patient’s medical record.

14. Counterparts and Electronic Signatures. This TOS may be executed in any number of counterparts, all of which shall constitute one and the same instrument, and any party to this TOS, may execute it by signing and delivering one or more counterparts. Each party agrees that this TOS and any of its related documents may be electronically signed. The parties further agree that any electronic signatures appearing on this TOS, or its related documents are, and shall be considered, the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

APPENDIX A

SERVICES

Medical Services. Patient may receive the Medical Services identified below, as deemed appropriate under the circumstances, at the sole discretion of Your physician. The Physician does not regularly prescribe scheduled (controlled) drugs. Unless otherwise stated, the Patient is responsible for all costs associated with any medications, laboratory testing, imaging, pathology, specimen analysis, etc., related to these Services.*

Comprehensive Initial Consultation – 675$

A detailed review of your medical records and test results prior to the appointment (up to 1 hour)
Comprehensive virtual consultation with Dr. Danve (1 hour)
Guidance about next steps including ordering of the lab & imaging tests as deemed necessary.
Development of detailed and personalized treatment plan
Prescribing medications as necessary
Follow up visit to discuss the lab and imaging results (within 30 days)
Communication and care coordination with the patient’s other physicians as appropriate.

Initial Consultation /Second Opinion Consultation – 525$

A detailed review of your medical records and test results prior to the appointment (up to 1 hour)
Comprehensive virtual consultation with Dr. Danve (1 hour)
Guidance on next steps including ordering of additional lab & imaging tests as deemed necessary.
Development of detailed and personalized treatment plan
Prescribing medications as necessary
Communication and care coordination with Patient’s other physicians as appropriate.

Follow up appointment – 275$

One on one follow-up appointment with Dr. Danve after an initial consultation (30 – 45 minutes)
Subsequent ordering and monitoring of labs, imaging, and other testing as necessary.
Prescribing medications as necessary.
Communication and care coordination with the patient’s other physicians as appropriate.

*The Patient is responsible for all fees associated with any medications, products, laboratory testing , imaging, specimen analysis, etc., related to the above Services.

Non- Medical Personalized Services. The Practice shall also provide Members with the following non-medical services and amenities:

After-Hours Access. Subject to the limitations of paragraph 10 of the TOS, Members will have direct telephone access to their physician during regular business hours. In addition, video chat and text messaging may be employed when the physician and patient agree that it is appropriate. Notwithstanding the above, the Member understands that this TOS is not for ongoing primary care, emergency or urgent care.

Direct Electronic Access. Members shall be provided with direct electronic access (through means such as email, patient portal, etc.), through which they can directly address their physician in regard to non-urgent matters. Such communications shall be dealt with during regular business hours. The Member understands that email, text messaging, direct messages through social media and other forms of electronic communication should never be used to obtain medical assistance or care in an urgent situation. The Member understands and agrees that in any situation that could reasonably be expected to develop into an emergency, the Member shall immediately call 911 or proceed to the nearest emergency medical care provider.
On-Time Appointments. Subject to the limitations of paragraph 10 of the TOS, Members shall be seen on time for scheduled visits. If the physician foresees more than a minimal wait time, the Member shall be contacted and given the option of either having their visit at a later time or rescheduling the appointment.
Same day/next day Appointments. Subject to the limitations of paragraph 13 of the TOS, Patients requesting it, shall be scheduled for same day/next day appointments (during regularly scheduled office hours) as appropriate.
Specialist Coordination. Your physician shall be available to coordinate care with your outside specialists or other providers as appropriate. This TOS does not cover or include specialists’ fees or fees from any medical professional other than the Practice staff.

APPENDIX C

FEE ITEMIZATION

Comprehensive Initial Consultation $675.

Initial/Second Opinion Consultation $575.

Follow Up Appointment $275.