PATIENT AGREEMENT & DISCLOSURE STATEMENT
I acknowledge and understand that I am voluntarily becoming an PeopleOne Health patient and that this agreement is nontransferable.
I acknowledge and understand that this agreement does not provide comprehensive health insurance coverage nor is it a contract of insurance.
I acknowledge and understand that I am responsible for the monthly access fee and any charges incurred for health care services performed outside of PeopleOne Health including but not limited to emergency room, hospital and specialty services, advance imaging, and that PeopleOne Health will not bill insurance carriers for any services provided by PeopleOne Health. The payment for adult vaccinations administered at PeopleOne Health and for third party laboratory fees not covered by my insurance will be my responsibility and are due and payable at the time of services.
I acknowledge and understand that PeopleOne 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 understand and acknowledge that this policy is available upon request.
I acknowledge and agree to pay my monthly care fee on or before its due date. In the event that I am unable to pay me fee(s) on time, I understand that I will be charged a $25 late fee and that my service agreement may be terminated.
I acknowledge and understand that I may terminate this Patient Agreement at any time and for any or for no reason by providing written notice to PeopleOne Health. Monthly fees with continue to accrue until written termination notice is received. I acknowledge that any notifications received after the 15th of the month will not be subject to a prorated refund.
In addition, I acknowledge and understand that PeopleOne Health may terminate this Patient Agreement for cause due to non-payment or fees, or for unruly, threatening or inappropriate behavior by providing me written notice and any pre-paid monthly fees will be prorated to the date of termination and returned to me within 30 days business days. PeopleOne Health will not terminate this Patient Agreement solely on the basis of health status.
I acknowledge and understand that PeopleOne Health may add or discontinue services or may increase my fee schedule at any time (but no more than once per year), and that I will be given, in writing, at least 60 days notice of such fee schedule changes.
I acknowledge and understand that if I am enrolled in Medicare I will receive a copy of the Medicare Opt-Out Agreement for review and signature before my first appointment. (The Opt-Out Agreement does not prevent me from receiving current or future Medicare benefits from non-PeopleOne Health providers; neither I nor my PeopleOne Health health care provider(s) will seek reimbursement from Medicare for the medical services I receive from PeopleOne Health.
RIGHTS AND RESPONSIBILITIES
I understand that I have the right to a fair, fast and objective review of any complaint I have against my health care clinician(s) or any other staff, including complaints about wait times, operating hours, conduct of personnel, business practices, and adequacy of health care services and facilities. I agree to first bring any complaints to the attention of PeopleOne Health staff and to participate in the PeopleOne Health complaint and grievance process.
In order to receive the best possible care, I agree to be actively involved in my health care decisions and to disclose all relevant information to my PeopleOne Health health care clinician(s) so that they can help me achieve my health goals. I also agree to inform my PeopleOne Health health care clinician(s) of any health care services I receive outside of PeopleOne Health (such as the emergency room, specialist, or hospital services).
I understand that I am responsible for not exposing myself or others to disease or danger. I understand that I can receive information from my PeopleOne Health health care clinician(s) about protecting the health and safety of myself and others.