SCHEDULE A Membership Enrollment Form Individual Plan Family Plan Member s Name: E-Mail Address: Address: Home Phone Number: Cell Phone: Fax Number: Work Phone: Preferred contact method: TEXT PHONE EMAIL OTHER: Enrolled Family Members: You understand and agree that enrollment as a member of North Okaloosa Family Medicine, PLLC, is contingent upon you and your family members signing releases allowing North Okaloosa Family Medicine, PLLC to obtain and review a copy of your complete medical records. You also understand and agree that you are financially responsible for all charges and fees for services provided to all enrolled members of your family. Preferred Pharmacy:
SCHEDULE B Fees Membership Fees: The first month s Membership Fee must be paid in full prior to commencement of services unless otherwise agreed in writing by North Okaloosa Family Medicine, PLLC. Failure to pay Membership Fees will result in being unenrolled from the program and ineligible for services. The following fees apply for 2017-18: Annual Enrollment Fee (Individual): Annual Enrollment Fee (Family): Monthly Membership Fees: Newborn to 17 y/o: $10.00* 18 to 44 y/o: $50.00 45 to 64 y/o: $60.00 65 and older: $75.00 * Requires at least one (1) adult membership (e.g. parent, grandparent, or legal guardian) House Calls and After Hours Telemedicine Visits: All house calls and after hours telemedicine visits will be charged an additional convenience fee. The services provided during any house call or after hours telemedicine visit are those listed in the Menu of Services which may be amended from time to time by North Okaloosa Family Medicine, PLLC, and do not include fees for additional services as outlined in Schedule C. The house call and after hours telemedicine convenience fees are: House Calls: $10.00 per patient, per visit during business hours $10.00 per patient, per visit after hours After Hours Telemedicine: $0.00 per patient, per visit After Hours is defined as after 6pm Monday - Friday and anytime on weekends or legal holidays.
SCHEDULE C Menu of Services I. Subject to certain limitations such as equipment failures or unforeseen supply or staffing shortages, North Okaloosa Family Medicine, PLLC, provides the following list of services: - All office visits o E.g. well and sick visits; school, sports and camp physicals, well woman exams - Chronic disease management (when within Dr. Bailey s training and expertise) - General health advice and counseling - Prescriptions - In-office diagnostic testing (when supplies and equipment are available) such as: o EKG o Rapid Strep o Blood glucose o Pulse oximetry o Urinalysis (dipstick in office) o Fecal occult blood o Urine pregnancy - Telephone/telemedicine consultations * - E-mail and text communication - Home visits ** - Laceration repair (tissue adhesive or stitches) - Skin tag/mole removal - Skin biopsy - Abscess incision and drainage - Ingrown nail repair - Non-operative foreign body removal (e.g. from skin, ear, etc.) - Basic wound care - Splinting or wrapping of sprains, strains, or minor fractures - Referral to any and all necessary specialists - Orders for all diagnostic tests not able to be provided by the Practice The Practice reserves the right to decline to perform any of the above-listed services, tests, or procedures in the event they are inappropriate, contraindicated, or otherwise not medically necessary. The determination to decline to perform any particular service is up to the complete discretion of Dr. Bailey or another of the Practice s providers as appropriate. Additional fees may apply for other goods and services, but every effort will be made to keep those fees to a minimum. You will be advised by the Practice prior to incurring any charge. * Additional fee applies to after hours telephone/telemedicine visits ** Additional fee applies to home visits, and may be declined by the Practice in its own discretion
II. North Okaloosa Family Medicine, PLLC, DOES NOT provide any of the following services: - Diagnostic imaging such as: x-rays, CT scans, MRIs, ultrasounds, and other medical imaging - Laboratory testing not able to be performed in the Practice s office even if the sample is drawn in the office - Surgery - The cost of immunization drugs (no fee is assessed for the administration itself) - Obstetrical care of any kind - In-patient hospitalizations - Prescription medications - Durable medical equipment (e.g. crutches, wheelchairs, casts, walking boots, etc.) - Injectable medications III. House Call/Home Visit fees include: - Travel - Physical Exam - History of the Problem - Any procedure that would be performed in the office at no additional cost - The same service and fee exclusions apply to house calls/home visits You understand and agree that due to the nature of treating a patient in a setting outside the Practice s office, there are certain natural limitations (e.g. equipment, supplies, sterility etc.) that prohibit the provision of certain services that may have otherwise been available to you had the visit taken place in the office. The following services are specifically excluded from house calls/home visits: - EKG - Vaccines (including flu shots) - Blood tests - Urine Tests - Prescription medication
SCHEDULE D Medicare and Medicaid Opt Out Agreement This Agreement is entered into by and between North Okaloosa Family Medicine, PLLC, a Florida professional limited liability company (the Practice ), whose principal office is located at 951 South Ferdon Boulevard, Crestview, Florida 32536, and a beneficiary enrolled in Medicaid, Medicaid Managed Care, CHIP, Medicare Part B or C, or any other federal or state funded health care program ( Beneficiary ), whose name and address is: Introduction The Balanced Budget Act of 1997 allows health care practitioners to opt out of Medicare and enter into private contracts with patients who are Medicare beneficiaries. In order to opt out, health care practitioners are required to file an affidavit with each Medicare carrier that has jurisdiction over claims that they have filed (or would have jurisdiction over claims had the practitioner not opted out of Medicare). In essence, the practitioner must agree not to submit any Medicare claims nor receive any payment from Medicare for items or services provided by the practitioner to any Medicare beneficiary for two years. This Agreement between Beneficiary and Practice is intended to be the contract practitioners are required to have with Medicare beneficiaries when practitioners opt-out of Medicare. This Agreement is limited to the financial agreement between Practice and Beneficiary and is not intended to obligate either party to a specific course or duration of treatment. Practice s Responsibilities (1) Practice agrees to provide Beneficiary such treatment as may be mutually agreed upon and at mutually agreed upon fees. (2) Practice agrees not to submit any claims under the Medicare program for any items or services provided or furnished by it, even if such items or services are otherwise covered by Medicare. (3) Practice agrees not to execute this contract at a time when Beneficiary is facing an emergency or urgent healthcare situation. (4) Practice agrees to provide Beneficiary with a signed copy of this document before items or services are furnished to Beneficiary under its terms. Practice also agrees to retain a copy of this document for the duration of the opt-out period. (5) Practice agrees to submit copies of this contract to the Centers for Medicare and Medicaid Services (CMS) upon the request of CMS.
Beneficiary s Responsibilities (1) Beneficiary agrees to pay for all items or services furnished by Practice and understands that no reimbursement will be provided under the Medicare program, or any other state or federally funded program, for the items or services provided or furnished by the Practice. (2) Beneficiary understands that no limits under the Medicare program, or any other state or federally funded program, apply to amounts that may be charged by Practice for such items or services. (3) Beneficiary agrees not to submit a claim to any federal or state funded health insurance program and not to ask Practice to submit a claim to those entities for any items or services provided or furnished by the Practice. (4) Beneficiary understands that no payment will be made for any items or services furnished by Practice that otherwise would have been covered by Medicare or any other state or federally funded program if there were no private contract and a proper claim had been submitted. (5) Beneficiary understands that Beneficiary has the right to obtain covered items and services from physicians and practitioners who have not opted out of government funded health care programs, and that Beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered items or services furnished by other physicians or practitioners who have not opted out of Medicare. (6) Beneficiary understands that Medigap plans (under section 1882 of the Social Security Act) do not, and other supplemental insurance plans may elect not to, make payments for such items and services paid for by Medicare. (7) Beneficiary understands that CMS has the right to obtain copies of this contract upon request. Note: This Agreement covers items and services furnished by the Practice and does not affect other rights the Beneficiary may have under any state or federally funded health care program. Medicare Exclusion Status of Practice Beneficiary understands the Practice and its providers have not been excluded from participation under the Medicare program under section 1128, 1156, 1892, or any other sections of the Social Security Act. The Practice has voluntarily opted out of the Medicare program.
Duration of the Contract This contract becomes effective on, 20 and will continue in effect until, 20. Either party may terminate treatment with reasonable notice to the other party. Notwithstanding this right to terminate treatment, both Practice and Beneficiary agree that the obligation not to pursue Medicare reimbursement for items and services provided under this contract will survive this contract. The parties agree that this agreement will be fully binding on their heirs, successors, and assigns. Physician and Beneficiary intend to be legally bound by signing this agreement on the date set forth below. NORTH OKALOOSA FAMILY MEDICINE, PLLC By: / Jimmie D. Bailey II, M.D., President Date MEMBER/BENEFICIARY By: / Name Date For himself/herself and on behalf of his/her family Print