This is an Agreement entered by and between Euphora Health, a Texas professional corporation, located at 711 W. 38th Street, Suite D1, Austin, TX 78705 (“Euphora Health”), Chris Larson, D.O. (Physician) or other practit ioners, in their capacity as agents of Euphora Health, and the signer (Patient).
The Patient is voluntarily becoming a member of Euphora Health.
The Physician, who specializes in family medicine, delivers care on behalf of Euphora Health. In exchange for certain fees paid by Patient, Euphora Health, through its Physician or other practitioners, agrees to provide Patient with the Services described in this Agreement on the terms and conditions set forth in this Agreement. This Agreement will replace and make void any previous Agreement between Euphora Health and the Patient. This Agreement shall commence on the date signed by the parties below and shall continue for a period of one year. This Agreement shall be automatically renewed unless a notice of cancellation is submitted by either party.
This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient.
I have reviewed the Patient Policies and have had an opportunity to ask questions and receive answers regarding the policies.
As used in this Agreement, the term Services, shall mean a package of services, both medical and non-Medical, and certain amenities (collectively "Services"), which are offered by Euphora Health, and set forth below under Exhibit A.
I understand that the Patient will be provided a limited set of services at no extra charge, including unlimited doctor/practitioner/nurse visits during regular business hours, communication with physician/practitioner after hours for urgent issues, limited diagnostic testing (rapid strep, in clinic urinalysis, urine pregnancy, mononucleosis test, finger stick blood glucose), procedures (laceration repair, toenail removal, incision and drainage, EKG), and coordination of care.
I understand that the Patient will also have access to discounted prices on labs and medication administered at the Euphora Health clinic.
The services are limited to those typical of family medicine and may be further limited by access to equipment, medicine, and/or technology.
The ongoing services offered to each Patient may be changed at the discretion Euphora Health.
The services offered during a single visit are at the discretion of the treating provider.
Patients may require medical treatment(s) that are not available at Euphora Health. I understand that there may be times that I cannot contact an Euphora Health practitioner due to vacations, illness, or technical abnormalities. I understand that should an Euphora Health practitioner become unavailable, Euphora Health will use its best efforts to arrange for coverage to be provided under the terms of this Agreement for its Patients with another health care
provider. However, this coverage cannot be guaranteed at all times. Euphora Health may use nurses, physician assistants, medical assistants and other staff to assist in providing care. Euphora Health shall use its discretion to determine the appropriate personnel to complete a patient visit, test or procedure. All such personnel will be bound by this Patient Agreement.
- I understand that fees incurred at the time of service must be paid at that time.
- In the event that the monthly membership fees are not paid on time, I understand that my service Agreement may be terminated.
- I understand that some services at Euphora Health require additional charges including labs, venipuncture fees, medication given in clinic, and administration fees. These fees are subject to change without notice, but Euphora Health will always disclose any charges prior to rendering service.
- I acknowledge and understand that Euphora Health may add or discontinue included services without notice.
- I acknowledge and understand that I am responsible for any charges incurred for health care services outside of Euphora Health including but not limited to emergency room, urgent care, hospital and specialty services, imaging, labs, and pharmaceuticals.
- I acknowledge that Euphora Health will not be required to reimburse me for any charges the Patient may incur for any care outside of the Euphora Health clinic.
- By signing below, I hereby authorize Euphora Health to initiate charges to my credit card, debit card, or bank account for any incidental fees that I incur or have incurred on my account since my last billing date.
- I acknowledge and understand that this Agreement does not provide comprehensive health insurance coverage nor is it a contract of insurance and that it provides only the health care services specifically described within this Agreement.
- I understand that this Agreement does not substitute for health insurance.
- I understand that Euphora Health will not bill insurance carriers, Medicaid, Medicare, or Medicare advantage health plans for any service provided by Euphora Health.
- I understand that Euphora Health does not guarantee reimbursement for any Euphora Health service or fees from any third-party health plans, including insurance plans and savings accounts (health savings or flexible spending).
- I confirm that the Patient is not a Medicare beneficiary, and is not currently enrolled in a Medicare plan.
- I understand that Euphora Health does not currently accept Medicare beneficiaries as patients, and a Medicare beneficiary may not currently become a Patient at Euphora Health.
- I understand that I must immediately notify Euphora Health of the Patient being enrolled in Medicare for any reason.
- I agree to never seek reimbursement for payments made to Euphora Health from Medicaid, Medicare or Medicare advantage health plans.
- I acknowledge and understand that either Euphora Health or the Patient may cancel this Agreement at any time and for any reason, without condition.
- I understand that Euphora Health will not terminate this Agreement solely on the basis of health status of the Patient.
- I understand that I must provide written Notification of Cancellation and that fees will continue to be billed or auto-charged until Euphora Health receives such notification.
- I understand that Euphora Health may terminate this Patient Agreement for cause due to non-payment of fees.
- I understand that a re-enrollment fee will be required to join as a Patient after cancellation of this Agreement (either by Patient’s choice or because of non-payment). Re-enrollment is dependent upon space being available within the practice.
HIPAA, Privacy and Communications
- I understand that under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and its subsequent regulations and Texas privacy laws I have certain rights to privacy regarding my protected health information (“PHI”).
- I have reviewed Euphora Health’s Notice of Privacy Practices and understand my rights contained in the notice and acknowledge that it is available online or by request.
- I acknowledge and understand that Euphora Health must maintain a record of my health information and must protect the privacy of my health information as per the terms of the Notice of Privacy Practices.
- I provide Euphora Health with my authorization and consent to use and disclose my PHI for the purposes described in the Notice of Privacy Practices.
- I understand that any and all methods of correspondence may be added by Euphora Health to the Patient’s documented medical record.
- I understand that Euphora Health may offer, but does not require, some forms of communication (including web-based unencrypted email, facsimile, text message, picture messaging, social media, online video conferencing) that cannot be guaranteed to be secure. However, Euphora Health makes every effort to comply with applicable federal and state privacy rules and regulations.
- I understand and agree that electronic communication is not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation in which the Patient could reasonably expect to develop into an emergency, the Patient shall call 911 and follow the directions of emergency personnel.
- I understand that if the Patient does not receive a response to an e-mail message within two days, Patient agrees to use another means of communication to contact the Physician. Neither Austin Osteopathic Family Medicine, nor the Practitioner will be liable to Patient for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient 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, or failure to properly address electronic 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 electronic communications set forth in this paragraph.
- “Services” are defined to include the following:
- All office visits provided by a physician, physician assistant or nurse practitioner;
- In-office tests (Rapid strep, blood glucose, in clinic urinalysis, urine pregnancy, mononucleosis test, finger stick blood glucose);
- In-office procedures (skin biopsy, toenail removal, incision and drainage)and coordination of care;
- Communication by phone, e-mail, and text; and
- Laceration repair (tissue adhesive, stitches, or staples).