Members with Visits User Agreement
This is an agreement (“Agreement”) between Dr. Gwenn Rosenberg (the “Physician”) located at 154 Hempstead St, New London, CT 06320 and __you and/or the patient__ (the “Patient”).
Background
The Physician delivers naturopathic care in New London, Connecticut in exchange for monthly fees paid by the Patient. The Physician agrees to provide the Patient with the Services described in this Agreement on the terms and conditions set forth in this Agreement.
Definitions
1. Engagement. The Patient hereby engages the Physician for ongoing naturopathic clinical services, which shall include clinical medical care services and health education services as described in the attached Appendix A (the “Services”).
2. Access. The Patient will be provided with methods to contact the Physician via phone, email, and electronic health records messaging. The Physician 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.
3. Fees. In exchange for the Services, Patient agrees to pay the Physician the amount as set forth in Appendix 1 and 2, attached. Applicable enrollment fees are payable upon execution of this Agreement.
4. Non-participation in Insurance. Patient acknowledges that the Physician does not participate in any health insurance or HMO plans besides Husky/Medicaid. The Physician does not participate in Medicare. The Physician makes no representations regarding third party insurance reimbursement of fees paid under this Agreement. The Patient shall remain fully and completely responsible for all payments due hereunder. Patient is aware that Medicare does not cover services rendered by a Naturopathic Physician.
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. It will not cover hospital services or any services not personally provided by the Physician or her associates. Patient acknowledges that the Physician has advised Patient to obtain or maintain such health insurance policies that will cover Patient for general healthcare costs. This Agreement is for ongoing naturopathic care and may be primary care for some Patients and the Patient will need to visit the emergency room or urgent care as needed. Physician will exercise diligent effort to be available or have coverage at all times during normal business hours via phone and email. This Agreement does not guarantee 24/7 availability.
6. Term. This Agreement will commence on the date it is signed by the Patient and Physician below and will extend monthly thereafter. Notwithstanding the above, both Patient and Physician shall have the absolute and unconditional right to terminate this Agreement without the showing of any cause for termination. The Patient may terminate this Agreement with twenty-four (24) hours’ prior notice but the Physician shall give thirty (30) days’ prior written notice to the Patient and shall provide the Patient with a list of other practitioners in the community in a manner consistent with applicable laws and regulations related to dismissal of patients. Unless previously terminated as set forth above, at the expiration of the initial one-month term (and each succeeding monthly term), the Agreement will automatically renew for successive monthly terms upon the payment of the monthly fee at the beginning of the contract month.
7. Privacy and Communications. Patient acknowledges that communications with the Physician using email, facsimile, video chat, instant messaging and cell phone are not guaranteed to be secure or confidential methods of communication. The Physician will make an effort to secure all communications via passwords and other protective means. The Physician will make an effort to promote the utilization of the most secure methods of communication, such as software platforms with data encryption and HIPAA Business Associate Agreements. This may mean that conversations over certain communication platforms are highlighted as preferable based on higher levels of encryption, but many forms of communication, 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 Physician and Physician’s office staff and associates to communicate with the Patient communicating PHI in the same format. Workshops and seminars will be recorded and available for Patient to watch. A Patient who asks a question or shares PHI during a workshop or seminar shall be deemed to have agreed to the recording of that question or statement recorded. If Patient has a question and does not wish to be recorded, the Patient may email or message the question or ask the Physician after the session.
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, in its modified form, consistent with applicable law, rendering that provision enforceable.
9. Reimbursement for Services if agreement is invalidated. If this Agreement is determined to be unlawful, invalid or unenforceable for any reason, and if Physician is therefore required to refund all or any portion of the monthly fees paid by Patient, Patient agrees to pay Physician 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 the Patient.
11. Jurisdiction. This agreement shall be governed and construed under the laws of the state of Connecticut and venue for all disputes arising out of this Agreement shall be in the Judicial District of New London County, Connecticut.
12. Patient understandings (initial each):
__X__ This Agreement is for ongoing care by a naturopathic Physician and is NOT a medical insurance agreement
__X__In the event of an emergency, I agree to call 911 first.
__X__I do not expect the Physician to file or contest any third party insurance claims on my behalf.
__X__In the event I have a complaint about the Physician, I will first notify the Physician directly.
__X__ I am enrolling (myself and my family if applicable) in the Physician’s naturopathic practice voluntarily
__X__ I may receive a copy of this Agreement upon request
__X__ This Agreement is non-transferable
Appendix 1- Dr. Gwenn Rosenberg Periodic and Enrollment Fees
This Agreement is for ongoing naturopathic care. This 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.
Fee Schedule
Enrollment Fee: this is charged when the Patient enrolls with the Physician’s practice and is nonrefundable. The enrollment fee is subject to change and is waived for current Patients through March 15, 2022. If a Patient discontinues membership and wishes to re-enroll in the practice, Physician reserves the right to decline re-enrollment or to require a re-enrollment fee. The enrollment fee as of the date hereof is $100.
Monthly periodic fee.
Patient agrees to pay the Physician a monthly period fee in advance for ongoing naturopathic care Services. Payment of the monthly period fee entitles the Patient to twenty (20) scheduled in-person visits per year. Each scheduled in-person visit in excess of twenty (20) will be charged at the rate of $50 per visit, payable on the day of the visit. The monthly periodic fee as of the date hereof is $144 per month which will be billed on day of the month that the Patient initially enrolled. The monthly periodic fee is subject to change on thirty (30) days’ notice to the Patient.
Acceptance of Patients
The Physician reserves the right to accept or decline patients seeking Services based upon Physician’s capacity to appropriately handle the Patient’s needs. Physician may decline new patients if the Physician’s panel of Patients is full or because the Patient requires medical care not within the Physician’s scope of Services.
Health Education Seminars and Workshops
These health education opportunities are included in membership and will be recorded so that people can access them if they are unable to attend. The health education seminars and workshops are not a substitute for one on one medical care. Patient shall consult with Physician or another physician with regard to any health issues or symptoms Patient is experiencing. The seminars and workshops are designed to provide further information but are not for diagnosis or treatment of any condition.