DIRECT PRIMARY CARE / FUNCTIONAL MEDICINE MEMBERSHIP PATIENT AGREEMENTS
This is an Agreement between Your Wellness MD (Practice), Karla L. Birkholz (Physician) in her capacity as an agent of Your Wellness MD, and you (Patient).
Dr. Birkholz, a practicing family medicine and functional medicine Physician, delivers care on behalf of Your Wellness MD, in exchange for fees paid by you, the patient. Your Wellness MD agrees to provide you, the Patient, with the services outlined in this Agreement according to the terms and conditions set forth herein. Your signature (online or in person) confirms your agreement to the terms and conditions set forth in this document and is legally binding.
The practice website is www.yourwellnessmd.net.
1. Physician -Dr. Birkholz, a practicing primary care and functional medicine Physician, delivers care on behalf of Your Wellness MD, in exchange for fees paid by you, the patient. She is licensed to practice medicine and prescribe for her patients in the states of Arizona, California and Colorado. Outside of those states she offers consultations for an hourly fee.
2. Patient. A patient is defined as those persons for whom the Physician shall provide Services, and/or those who are signatories to those patients named on Appendix 1, and incorporated by reference, to this agreement. A patient membership is non transferable.
2. Services. As used in this Agreement, the term Services, shall mean a package of ongoing Direct Primary Care and/or Functional Medicine services, both medical and non-medical, and certain amenities (collectively called “Services”), which are offered by the Practice, and clarified in Appendix 1 and 2.
Ongoing membership in the Direct Primary Care and/or Functional Medicine programs are included in the pricing agreements outlined in APPENDIX 1 below.
3. Provider Availability and Scheduling: The Patient will be provided with methods to contact the physician via phone, email, and other methods of electronic communication. Physician will make every effort to address the needs of the Patient in a timely manner, but cannot guarantee availability, and cannot guarantee that the patient will not need to seek treatment in the urgent care or an emergency department setting if needed. Patients must schedule sessions in advance via the online scheduler on the website. Patients may email (via Elation Passport) or text (via Spruce App) the Physician at any time. Physician will make every effort to return those electronic communication within 24 hours. Patient must allow at least 72 hours for a prescription refill request to be sent into the pharmacy.
Health coaching sessions will be scheduled online in advance via the online scheduler on the website. Your Health Coach will check your Electronic Medical record for any previous communications on the day of your health coaching appointment only. Health Coaches are not available on Spruce, nor do they check emails on Elation Passport unless they are scheduled to see you that day. If there is a time sensitive or urgent communication, please contact the Physician instead of the Health Coach via Elation Passport or Spruce.
4. Fees. In exchange for the services described herein, the Patient agrees to pay the Practice the amount set forth in Appendix 1 and 2, below. Applicable enrollment fees may be required and are payable upon execution of this agreement if and when membership is activated via HINT. If this Agreement is terminated by either party, no additional payment will be required after the end of the final month in which membership is terminated. HOWEVER if patient wishes to terminate membership, they must give notice of their wish to terminate no less than 5 days before their next billing cycle. If notice is given after 5 days prior to the next month's billing cycle, the monthly membership payment will proceed. In this case membership services will be extended for one additional month, and no refund will be offered with no exceptions. If membership has been pre- paid for a discounted fee, no refunds will be made.
5. Non-Participation in Insurance. Patient acknowledges that neither Practice, nor the Physician(s) of Health Coach(es) participate in ANY health insurance or HMO plans. Physician(s) have opted out of Medicare. Patient acknowledges that federal regulations REQUIRE that Direct primary Care Physicians opt out of Medicare so that Medicare patients may be seen by this Practice (pursuant to this private direct primary care contract). Your Wellness MD will not provide billing codes for Physician visits (CPT codes) for the purpose of insurance reimbursement. Neither the Practice nor Physician(s) make any representations regarding third party insurance reimbursement of fees paid under this Agreement. The Patient shall retain full and complete responsibility for any such determination.
Insurance reimbursement for labs and imaging varies widely. Most Functional Medicine specialty labs are NOT covered by insurance, and Patient must be aware of and responsible for the full out of pocket retail cost of the labs before they are ordered and collected. Practice does not guarantee coverage, payment or reimbursement by insurance companies for any labs or tests. Patient is responsible for determining insurance coverage/reimbursement for any labs or tests done prior to obtaining those labs.
If the Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, then Patient will read and agree to the details outlined in Appendix 3. Once again, this agreement acknowledges your understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for you by the Physician or Health Coach at Your Wellness MD. You agree not to bill Medicare or attempt Medicare reimbursement for any such services.
6. Other Medical Coverage. Patient acknowledges and understands that this Agreement is not an insurance plan, and not a substitute for health insurance or other health plan coverage (such as membership in an HMO). It will not cover hospital services, urgent care, specialist visits or any services not personally provided by the Practice, its Physician or the Health Coach. Patient acknowledges that Practice has strongly advised that patient obtain or keep in full any health insurance policy/policies or plans that will cover the general healthcare and prescription costs of the patient. Not all insurance policies will cover prescriptions written by an out-of-network provider. In this case Your Wellness MD suggests that patients use the 3rd party App GOOD RX to seek an obtain substantial discounts on prescription medications.
Several discounted labs may be purchased directly through the practice for an up front and transparen, out of pocket cost. Your Wellness MD does not up-charge for any specialty labs and frequently passes along any available discounts to their clients.
This Agreement is for ongoing Direct Primary Care and/or Functional Medicine memberships with Your Wellness MD only. Again, the Patient may need to visit the emergency room, urgent care as well as other specialists from time to time which will require payment or insurance reimbursement that is not covered by this membership agreement with Your Wellness MD.
* Patient acknowledges that THIS AGREEMENT IS NOT A CONTRACT THAT PROVIDES HEALTH INSURANCE, does NOT meet the insurance requirements of the Affordable Care Act, does not cover any hospital, urgent care, specialist, imagery and/or laboratory costs, and is not intended to replace any existing or future health insurance or health plan coverage that Patient may carry.
7. Term and Termination. This Agreement will commence on 1) the date this agreement is signed by the Patient (either electronically or in person) and/or 2) when billing information is entered into HINT and/or 3) upon the initial new patient appointment with either Physician or Health Coach (whether or not billing information has been entered) and will extend monthly thereafter.
It is anticipated that a Functional Medicine membership will last for at least 6 months (or indefinitely) and that the patient will make every effort to participate and engage through the full duration of the 6 month program. The Functional Medicine program has a 3 month minimum enrollment. If a patient chooses to end their membership early, they will automatically be charged for three full months upon discontinuing their membership. No successive coaching sessions will be allocated after early cancellation of the six month program.
Many Functional Medicine patients choose to graduate to the Direct Primary Care membership at the end of 6 months.
It is understood that the Direct Primary Care membership is a model where the pricing is based on continuous care over a long term. This membership will continue indefinitely until the Patient gives written notice of desire to terminate membership.
Both Patient and Practice shall have the absolute and unconditional right to terminate the Agreement without showing any cause for termination. If this Agreement is terminated by either party, no additional payment will be required after the end of the final month in which membership is terminated.
Termination: If a patient wishes to discontinue membership, written notice must be given 5 days prior to the next billing cycle. If notice of desire to terminate is not given 5 days prior to the next billing cycle, the patient will be automatically be re-enrolled for the following month with no refunds given, no exceptions. If membership has been pre- paid for a discounted fee, no refunds will be made.
If the Practice terminates the contract, it shall give the Patient thirty days prior written notice and shall provide the patient with a list of other Practices/Providers in the community if requested, in a manner consistent with local patient abandonment laws. Unless previously terminated as set forth above, at the expiration of the initial one-month term (and each succeeding monthly term), the Agreement will automatically renew for successive monthly terms upon the payment of the monthly fee at the end of the contract month.
Re-enrollment: If a patient discontinues membership and wishes to re-enroll in the practice at a later date, we reserve the right to decline re-enrollment. Because ours is a model of continuous care, re-enrollment will require either a full year of DPC membership ($1548) or a full six months of Functional Membership membership ($2094) payable in full upon re-enrollment.
Examples of reasons the Practice may wish to terminate the agreement with the Patient may include but are not limited to:
Practice has a right to determine whom to accept as a patient, just as a patient has the right
to choose his or her physician. We reserve the right to accept or decline patients based upon our capability to appropriately handle the patient’s primary care needs. Practice may decline new patients because the Physician’s panel of patients is full, or because the patient requires medical care not within the Physician’s scope of services.
8. Privacy, Platforms & Communications: You acknowledge that the communication portals provided for e-mail and facsimile (via Elation Passport) and video chat, text messaging, and cell phone (via the Spruce App) are the secure and confidential methods of communications preferred by Your Wellness MD. The practice will secure all communications via Elation Passport and Spruce via passwords and other protective means as discussed in a Health Insurance Portability and Accountability Act (HIPAA) disclosure.
Any other means of communication (other than via Elation Passport and Spruce) are not HIPAA compliant and therefore discouraged. Conversations with the Physician over our HIPAA compliant communication platforms are highlighted as preferable and necessary based on higher levels of data encryption, even if they are less convenient.
If the Patient initiates a conversation in which the Patient discloses “Protected Health Information (PHI)” on a non HIPAA compliant communication platform, then the Patient has authorized the Practice to communicate with the Patient regarding PHI in the same format.
9. Severability: If, for any reason, any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of the Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable.
9. Assignment. This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient to any other person.
11. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Arizona, California and Colorado. And all disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for the Practice address in Phoenix, Arizona.
12. Patient Understandings:
________ This Agreement is for ongoing primary care and/or functional medicine or health coaching and is NOT a medical insurance agreement.
________ I do NOT have an emergency medical problem at this time.
________ In the event of a medical emergency, I agree to call 911 first.
________ I do NOT expect the practice to file or fight any third party insurance claims on my behalf nor provide CPT codes for insurance reimbursement.
________ I understand that I am responsible for any and all laboratory charges and that Dr. B frequently recommends specialty labs that are not covered by insurance.
________ I do NOT expect the practice to continuously prescribe controlled substances on my behalf. (These include commonly abused opioid medications, benzodiazepines, and stimulants.)
________I recognize that the Functional Medicine approach requires active participation, communication, cooperation and the implementation of positive, sustainable lifestyle changes to achieve the best outcomes.
________ I assume any and all risks inherent in making lifestyle changes, including the risks of trying new foods, supplements, diets and fitness programs.
________This agreement is not a guarantee of health results.
________ We ask that you schedule, and cancel if necessary, visits more than 48 hours in advance when possible.
________ In the event I have a complaint about the Practice, I will first notify the Physician or Health Coach directly.
________ I am enrolling myself (and my family if applicable) in the practice voluntarily.
________ This Agreement is non-transferable.
________ I may receive a copy of this document upon request, and it is available for printing and reference on the website via the “resources" tab on the main menu.
________ I acknowledge that entering my billing information in HINT is acknowledgement that I have read and agree to everything outlined in the patient agreement.
APPENDIX 1 - Periodic & Enrollment Fees at Your Wellness MD
This Agreement is for ongoing primary care. This is Agreement is NOT HEALTH INSURANCE and is NOT A HEALTH MAINTENANCE ORGANIZATION. The Patient may need to use the care of specialists, emergency rooms, and urgent care centers that are outside the scope of this Agreement. Physician will make an appropriate determination about the scope of primary care services offered by the Practice.
Enrollment Fee: This is charged when the Patient enrolls with the Practice and is nonrefundable. This fee is subject to change. Your initial membership enrollment fee is currently $ 0.
Monthly Periodic Fee: This fee is for ongoing Direct Primary Care or Functional Medicine services with Dr. Birkholz, the Physician, with multiple routes of electronic and telephone communication. The number of patient encounters is not capped, nor is there a mandatory minimum. You are paying for our ongoing availability and our model of continuous care. You will decide how frequently to engage the Physicians' services based on your availability and ours. Most Functional Medicine members choose to schedule with the Physician monthly, and Direct Primary Care members schedule and communicate as needed.
The monthly periodic fee is currently $129 for the Direct Primary Care membership or $349 per month for the Functional Medicine membership. For effective results, patients are expected to maintain enrollment in the DPC practice for at least one year and the Functional Medicine membership for the full 6 months of the program. Functional Medicine members are encouraged to schedule 10 complimentary Health Coaching sessions during their six month program. Health coaching sessions are considered supportive and adjunctive to the Functional Medicine program and are not required.
APPENDIX 2 Your Wellness MD Itemized Services and Fees
Ongoing membership in the Direct Primary Care and/or Functional Medicine programs are included in the pricing agreements outlined in APPENDIX 1 above.
Direct Primary Care Membership-
Functional Medicine Membership-
Health Coaching: The Functional Medicine membership includes 10 complimentary 50 minute health coaching sessions. These sessions are not mandatory and are offered as supportive and adjunct therapy for our Functional Medicine clients in order to initiate and sustain important lifestyle changes. The 10 Health Coaching sessions must be used within the allotted 6 months of the Functional Medicine membership and cannot be rolled over into future months.
Additional health coaching sessions are available will be offered at a price of $75/50 minute session. DPC members can also see the health coach for a discounted fee of $75/ month.
Ancillary Services: Some ancillary and vendor services may be available to you through Your Wellness MD. Examples of these ancillary services include specialty laboratory testing, radiologic testing, and dispensed medications or supplements and will be paid directly to Your Wellness MD.
Supplements and Medications will be ordered in the most cost effective manner possible for the patient without sacrificing quality. To this end, Physician has enrolled with Fullscripts in order to ensure quality control. Some supplement purchases may result in a small profit to Your Wellness MD.
Some laboratory services are offered for discounted and/or directly negotiated fees from Your Wellness MD, OR you may choose to file a claim with your insurance company for reimbursement. Claim reimbursements vary wildly and the only way to ensure accurate pricing is to order your labs directly through Your Wellness MD.
Vaccinations are NOT offered in our office, nor are they covered by our membership plan.
Hospital Services are NOT covered by our membership plan, and due to mandatory “on call” duties required at local institutions we have elected NOT to obtain formal hospital admission privileges at this time.
Obstetric and Gynecologic Services are NOT covered by our membership plan.
In person, physical examinations and procedures are not covered by our membership plan at this time. Currently, all Direct Primary Care and Functional Medicine visits occur exclusively via video chat or phone. If in-person examinations or procedures are needed, Patient must seek out an urgent care physician or an appropriate specialist. Such services are not included in any membership agreements with Your Wellness MD.
APPENDIX 3 Your Wellness MD Medicare Patient Understandings
This agreement is between Your Wellness MD, and Medicare Beneficiary-
Patient is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. The Practice has informed Beneficiary or his/her legal representative that Physicians at the Practice have opted out of the Medicare program. The
Physicians in the Practice have not been excluded from participating in Medicare Part B under  1128,  1156, or  1892 of the Social Security Act.
Beneficiary or his/her legal representative agrees, understands and expressly acknowledges the following:
- Beneficiary or his/her legal representative accepts full responsibility for payment of the physician’s charge for all services furnished by the physician.
- Beneficiary or his/her legal representative understands that Medicare limits do not apply to what the physician may charge for items or services furnished by the physician.
- Beneficiary or his/her legal representative agrees not to submit a claim to Medicare or to ask the physician to submit a claim to Medicare.
- Beneficiary or his/her legal representative understands that Medicare payment will not be made for any items or services furnished by the physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
- Beneficiary or his/her legal representative enters into this contract with the knowledge that he/she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and the beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out.
- Beneficiary or his/her legal representative understands that Medicare supplemental plans generally do not make payments for items and services not paid for by Medicare.
- Beneficiary or his/her legal representative acknowledges that the beneficiary is not currently in an emergency or urgent health care situation.
- Beneficiary or his/her legal representative acknowledges that a copy of this contract has been made available to him.
By signing, either in person, or through online acknowledgement, I am agreeing to the legally binding terms and agreements set forth in this contract.
Guardian’s name (if applicable)
Signature of Patient or Guardian
Your Wellness MD is dedicated to achieving meaningful, measurable improvements in your health and well-being. We work to ensure that you have access to the care you need, when you need it, at a price you can afford...
© 2022 All Rights Reserved