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Patients’ Rights and Responsibilities
Member Rights You have the right to respectful and fair service from providers and staff at clinic powered by EverMed DPC. This care should be considerate of your cultural and personal beliefs. You have the right to be provided information concerning your health status, condition, and/or treatment options. You have the right to refuse treatment and be informed about the potential consequences of the refusal. You have the right to be informed, up front, about how much a recommended test or procedure will cost. If you feel you have not been treated with respect, you the right to speak with the clinic manager to resolve the issue. You have the right to a one time clinic change if you are unable to resolve the issue with the clinic. All other clinic changes will require approval from EverMed DPC. You have the right to cancel your membership. To cancel, you must fill out and turn in the Membership Cancellation Form. See Membership Cancellation policy for details. You have the right to seek and maintain insurance coverage for services not provided by your membership. Member Responsibilities Communicate respectfully to providers and staff at clinic powered by EverMed DPC. Provide complete and accurate information about past and current health status, any medications, any allergies, and any services received outside of the Direct Primary Care program (such as hospitalizations or visits to the emergency room). Ask questions if you do not understand what the provider is saying about your medical status or treatment plan. Come to appointments on time or call ahead if you cannot come to the appointment. Follow the treatment plan recommended by your provider. Get x-ray and lab services from a clinic you chose powered by EverMed DPC only. Inform staff about changes in address, phone number, and health insurance information. Provide current credit card, debit card, or bank account information to pay membership fees. If a charge is rejected by the bank and payment hasn’t been received within 30 days, EverMed DPC will suspend your membership. If payment isn’t received within 60 days the membership will be terminated.
Terms of Agreement This agreement does not provide comprehensive health insurance coverage. It provides only the health care services specifically described in the Included Services List. Clinics powered by EverMed DPC may make changes to the Included Services List from time to time. If any changes are made, the clinic powered by EverMed DPC will inform you in writing. Your clinic will not bill an insurance carrier for services covered under your EverMed DPC membership. EverMed DPC may change membership fees. If changes are made, EverMed DPC will give you 60 days’ notice in writing. EverMed DPC and/or the participating clinic may terminate membership or the Direct Primary Care program at any time. You will be notified in writing, with 30 days’ notice, of any such decisions. Financial Policy EverMed DPC will charge your credit card/debit card or deduct membership fees from your bank account on a regular basis. You are financially responsible for any procedure, test, or service provided that is not listed in the Included Services List. EverMed DPC may make changes to the Included Services List from time to time. If any changes are made, EverMed DPC will inform you in writing. If charges are sent to collections due to non-payment, your DPC membership may be subject to review and cancellation.
Cancellation Policy Patient may cancel this Direct Agreement at any time and for any reason. A cancellation form is provided to Patient at the clinic or through the portal. EverMed Services LLC will refund a prorated portion of the monthly membership to patient if membership is canceled with the month paid. EverMed Services LLC will process the refund of patients membership dues to the same account the patient used during enrollment within 1 – 3 business days. Availability of refunded dues may be delayed by third parties. Check with your bank for further details. During the twelve (12) month period after patient signs this Direct Agreement, we may only terminate this Direct Agreement for one of the following reasons:
Cancellation Policy-continued
a. b. c. d.
Patient fails to pay the direct fee under the terms required by this Direct Agreement; Patient performs an act that constitutes fraud; Patient repeatedly fails to comply with a recommended treatment plan; Patient is abusive and/or presents an emotional or physical danger to the staff or other patients; or e. The provider discontinues the Direct Primary Care membership program.
After cancelling the Direct Primary Care Agreement, patient will be responsible (with or without insurance) for any fees or charges associated with any care or services patient receives at the provider’s clinic after the date of cancellation. Patient will receive a letter confirming cancellation. If payment is returned Patient must pay membership within 30 days or membership will be suspended. If no payment has been made within 60 days membership will be terminated. If a patient cancels their Direct Primary Care three times within one year, the provider reserves the right to deny acceptance of the patient. *Direct Primary Care (DPC) is not insurance. It is not an insurance plan or agent, and it does not offer insurance plans. Direct Primary Care is a membership for primary care at a participating clinic of your choice. DPC, on its own does not satisfy ACA requirements and is best paired with an insurance plan.
