PATIENT AGREEMENT

White Mountain Health, LLC d/b/a

Iris Integrative Health

This is an Agreement entered into between White Mountain Health, LLC, a Hawaii Limited Liability Company, d/b/a Iris Integrative Health (Clinic, Us or We), and Patient (You), on date of Your joining Clinic.

Background

The Clinic is a Direct Pay primary care practice (DPC), which delivers primary care services through its providers, Dr. Robert B. Hollander III and Dr. Michelle Suber (Providers), at 65-1235A Opelo Road #6, Kamuela, Hawaii 96743.  In exchange for certain fees, the CLINIC, agrees to provide You with the Services described in this Agreement on the terms and conditions contained in this Agreement.

Definitions

1. Patient.  In this Agreement, “Patient” means the persons for whom the Providers shall provide care, and who have signed this agreement or are listed on the document attached as Appendix B, which is a part of this agreement.

2.  Services.  In this Agreement, “Services”, means the collection of services, offered to you by Us in this Agreement.  These Services are listed in Appendix A(1), which is attached and a part of this Agreement.

Agreement

3.  Term.  This Agreement will last for one year, starting on date of joining.

4. Renewal.  The Agreement will automatically renew each year on the anniversary date of the agreement, unless either party cancels the Agreement by giving 30 days written cancellation notice. 

5. Termination.  Regardless of anything written above, You always have the right to cancel this agreement.  Either party can end this agreement at any time by giving the other party 30 days written notice.

6.  Payments and Refunds – Amount and Methods.  In exchange for the Services (see Appendix A(1)), You agree to pay Us, a monthly or annual fee in the amount that appears in Appendix C, which is attached and is part of this Agreement. 

a) This monthly fee is payable when you join the clinic, and is due on the same day of each month thereafter; for annual payment, payment is due on joining the clinic, and every 365 days thereafter.

b) The Parties agree that the required method of monthly payment shall be by automatic payment, through a debit or credit card, unless otherwise agreed upon by both parties. For annual payment, payment by check is also accepted.

  

c) If this Agreement is cancelled by either party before the Agreement ends, We will review and settle your account by refunding You the unused portion of your fees on a per diem basis, once the 30 day period after written notice has passed.

7.  Non-Participation in Insurance.  Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its Providers, participate in any health insurance or HMO plans or panels and have opted out of Medicare.  Neither make any representations that the fees paid under this Agreement are covered by the Patient’s health insurance or other third party payment plans.  It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan or HSA and to submit any required billing.

8. Medicare.  This agreement acknowledges the Patient’s understanding that the Providers do not participate Medicare, and as a result, Medicare cannot be billed for any services performed for the Patient by the Providers.  The Patient agrees not to bill Medicare or attempt to obtain Medicare reimbursement for any such services.  If the Patient is eligible for Medicare, or becomes eligible during the term of this Agreement, then s/he will sign the Medicare Opt Out and Waiver Agreement attached as Appendix D and incorporated by reference.  The Patient shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law.

9.  This Is Not Health Insurance.  Your initials on this clause of the Agreement acknowledge Your understanding that this Agreement is not an insurance plan or a substitute for health insurance. The Patient understands that this Agreement does not replace any existing or future health insurance or health plan coverage that Patient may carry.  The Agreement does not include hospital services, or any services not personally provided by the CLINIC, or its employees.  The Patient acknowledges that the CLINIC has advised the patient to obtain or keep in full force, health insurance that will cover the Patient for healthcare not personally delivered by the CLINIC, and for hospitalizations and catastrophic events. 

10.  Communications.  The Patient acknowledges that although the CLINIC shall comply with HIPAA privacy requirements, communications with the Providers using e-mail, facsimile, video chat, cell phone, texting, and other forms of electronic communication can never be absolutely guaranteed to be secure or confidential methods of communications.  As such, Patient expressly waives the Providers’ obligation to guarantee confidentiality with respect to the above means of communication.  Patient further acknowledges that all such communications may become a part of the medical record.

By  providing  an  e-mail  address  on  the  attached  Appendix  B,  the  Patient authorizes the CLINIC, and its Providers to communicate with him/her by e-mail regarding the Patient’s “protected health information” (PHI).

  The Patient further acknowledges that:

  • a) E-mail is not necessarily a secure medium for sending or receiving PHI and, there is always a possibility that a third party may gain access – for this reason we recommend that the clinic’s more secure EMR “Patient Portal” be used whenever possible for email communications;
  • b) Although the Providers will make all reasonable efforts to keep e-mail communications confidential and secure, neither the CLINIC, nor the Providers can assure or guarantee the absolute confidentiality of e-mail communications;
  • c) At the discretion of the Providers, e-mail communications may be made a part of  Patient’s permanent medical record; and,
  • d) You understand and agree that e-mail is not an appropriate means of communication in an emergency, for time-sensitive problems, or for disclosing sensitive information.  In an emergency, or a situation that You could reasonably expect to develop into an emergency, You understand and agree to call 911 or the nearest Emergency room, and follow the directions of emergency personnel.
  • e) Email Usage.  Providers check their e-mail frequently on weekdays, during business hours.  If You do not receive a response to an e-mail message by the next business day, You agree that you will contact a Provider by telephone or other means.
  • f) Technical Failure.  Neither the CLINIC, nor the Providers will be liable for any loss, injury, or expense arising from a delay in responding to Patient, when that delay is caused by technical failure.  Examples of technical failures (i) failures caused by an internet service provider, (ii) power outages, (iii) failure of electronic messaging software, or e-mail provider (iv) failure of the CLINIC’s computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of e-mail communications by a third party which is unauthorized by the CLINIC; or (v) Patient failure to comply with the guidelines for use of e-mail described in this Agreement.

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

11.   Change of Law.  If there is a change of any relevant law, regulation or rule, federal, state or local, which affects the terms of this Agreement, the parties agree to amend this Agreement to comply with the law.

12. Severability.  If any part of this Agreement is considered legally invalid or unenforceable by a court of competent jurisdiction, that part will be amended to the extent necessary to be enforceable, and the remainder of the contract will stay in force as originally written.

13. Reimbursement for Services Rendered.  If this Agreement is held to be invalid for any reason, and the CLINIC is required to refund fees paid by You, You agree to pay the CLINIC an amount equal to the fair market value of the medical services You received during the time period for which the refunded fees were paid.

14. Amendment.  No amendment of this Agreement shall be binding on a party unless it is in writing and signed by all the parties.  Except for amendments made in compliance with Section 11, above. 

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

16. Legal Significance.  You acknowledge that this Agreement is a legal document and gives the parties 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.

17. Miscellaneous.  This   Agreement   shall   be   construed   without   regard   to   any rules requiring that it be construed against the party who drafted the Agreement. The captions in this Agreement are only for the sake of convenience and have no legal meaning.

18. Entire Agreement.  This Agreement contains the entire agreement between the parties and replaces any earlier understandings and agreements whether they are written or oral.

19.  No Waiver.  In order to allow for the flexibility of certain terms of the Agreement,  each party agrees that they may choose to delay or not to enforce the other party’s requirement or duty under this agreement (for example notice periods, payment terms, etc.).  Doing so will not constitute a waiver of that duty or responsibility.  The party will have the right to enforce such terms again at any time.

20. Jurisdiction.  This Agreement shall be governed and construed under the laws of the State of Hawaii.  All disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for the CLINIC in Kamuela, Hawaii.

21.  Service.  All written notices are deemed served if sent to the address of the party written above or appearing in Appendix B by first class U.S. mail.

By clicking the box marked, “I’ve read and accept the terms and conditions” after reviewing this document, You agree to abide by this Patient Agreement.

Appendix A

Services

  1. Medical Services.*  Medical Services under this agreement are those medical services that the Providers are permitted to perform under the laws of the State of Hawaii, are consistent with the Providers’ training and experience, are usual and customary for a family medicine and naturopathic medicine provider to provide, and include the following2:
  • Acute and Non-acute Office Visits
  • Well-Woman Care/ Pap Smear
  • Well-Baby and Well-Child Care
  • Electrocardiogram (EKG)
  • Blood Pressure Monitoring
  • Diabetic Monitoring
  • Breathing Treatments (nebulizer or inhaler with spacer)
  • Urinalysis
  • Rapid Test for Strep Throat
  • Removal of benign skin lesions/warts
  • Uncomplicated Skin Biopsies
  • Simple aspiration/injection of joint
  • Removal of Cerumen (ear wax)
  • Wound Repair and Sutures
  • Abscess Incision and Drainage
  • IV Fluids
  • Basic Vision/Hearing Screening
  • Naturopathic Treatment Modalities, including:
    • Hydrotherapy
    • Naturopathic spinal and joint adjustments
    • Homeopathy
  • Diet and weight loss counseling.

*Patient is responsible for all costs associated with any procedures, laboratory testing, and specimen analysis.

2  As deemed appropriate and medically necessary by the Physician.

The Patient is also entitled to a personalized, annual in-depth “wellness examination and evaluation,” which shall be performed by a Provider, and may include the following, as appropriate:

  • Detailed review of medical, family, and social history and update of medical record;
  • Personalized Health Risk Assessment utilizing current screening guidelines;
  • Preventative health counseling, which may include: weight management, smoking cessation, behavior modification, stress management, etc.;
  • Custom Wellness Plan to include recommendations for immunizations, additional screening tests/evaluations, fitness and dietary plans;
  • Complete physical exam & form completion as needed.
  • 2. Non-Medical, Personalized Services.  CLINIC shall also provide Patient with the following non-medical services (“Non-Medical Services”), which are complementary to our members in the course of care:
  • a) After Hours Access.  Patient shall have direct telephone access to a Provider seven days per week.  Patient shall be given a phone number where patient may reach a Provider directly for guidance regarding concerns that arise unexpectedly after office hours.  Video chat and text messaging may be utilized when a Provider and Patient agree that it is appropriate. 
  • b) Provider Absence.  From time to time, due to vacations, illness, or personal emergency, a Provider may be temporarily unavailable to provide the services referred to above in this paragraph one.  In order to assist Patients in scheduling non-urgent visits, CLINIC will notify Patients of any planned Provider absences as soon as the dates are confirmed.  In the event of a Provider’s unplanned absences, Patients will be given the name and telephone number of an appropriate provider for the Patient to contact.  Any treatment rendered by the substitute provider is not covered under this contract; patients will be notified if services would incur a charge, and if charges may be submitted to Patient’s health plan if so.
  • c) E-Mail Access.  Patient shall be given access to a Patient Portal where non-urgent communications can be e-mailed to Providers.  Such communications shall be dealt with by a Provider or staff member of CLINIC in a timely manner.  Patient understands and agrees that email and the internet should never be used to access medical care in the event of an emergency, or any situation that Patient could reasonably expect may develop into an emergency.  Patient agrees that in such situations, when a Patient cannot speak to a Provider immediately in person or by telephone, that Patient shall call 911 or the nearest emergency medical assistance provider, and follow the directions of emergency medical personnel.
  • d) Same Day/Next Day Appointments.  Every effort will be made to schedule a Patient with a Provider for time sensitive issues within two business days of requested appointment, and on the same day whenever possible.
  • e) Specialists Coordination.  CLINIC and Providers shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care.  Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the CLINIC Providers, although participation in the CLINIC’S direct primary care model does not preclude use of Patient’s medical insurance when seeing other providers.

Appendix B

FEE ITEMIZATION

Individual $145 per month

Couple $270 per month

Child $75 per month*

Each additional child: $35 per month

Enrollment Fee $100**

GE Tax of 4.125% added to all charges

*Without a fully enrolled adult member. 

**Non-refundable fee.  For all adult members and initial child member if no parent enrolled. Should your membership lapse or be terminated, the enrollment fee must be paid again but at $250 per adult patient for membership to become active.