We are not able to offer membership to clients enrolled in MEDICARE or MEDI-CAL (Medicaid). Please inform ACE Medical Inc Immediately if you are enrolled with any of these associated health plans.
1. MEMBERSHIP. Patient hereby agrees to enroll as a member in the practice’s direct addiction care membership program (“Membership Program”) beginning on the Effective Date of ______________. By being a member of the program, Patient shall be eligible to receive Remote Addiction Consultation and Home Based Urine Drug Screening. Membership in the Direct Addiction Care Membership Program includes only the covered services, specifically remote addiction consultation and home based urine drug screening.
2. MEMBERSHIP FEES. In addition to the initial membership application fee in the amount of six hundred dollars ($600.00), Patient agrees to pay additional continued service fees (“Membership Fee”) in accordance with the Addiction Change Experts (ACE) Medical Membership Fee Schedule. The initial membership application fee is due prior to the initial consultation, and continued service membership Fees shall be due prior to scheduling follow up consultation appointments.
Following the Effective Date, the membership will cover the Patient’s membership period selected from Direct Addiction Membership Fee Schedule. For the purposes of the membership, a month is defined as 30 days, and a year is defined as 365 days. Memberships will be valid until midnight on the last day of pre-paid membership.
Fees for non-covered services (example extra messaging for limited membership or for episodic vitis clients) shall be due at the time of service.
A. NONPAYMENT. In the event that the Patient is unable to pay the Membership Fee in full and on time, the Practice may, in its sole discretion, terminate this Membership Agreement
It is the Patient’s responsibility to maintain payment up-to-date
B. CHANGES TO MEMBERSHIP FEE SCHEDULE. The Practice may amend the Membership Fee Schedule at any time, as it may determine in its sole discretion, upon providing Patient at least 60 days’ advance written notice.
3. NON-COVERED SERVICES. Patients understand and acknowledge “membership program” includes remote consultation services and home based drug testing ONLY.
The Patient is responsible for any charges incurred for health care services performed at any physical office space location including, but not limited to, emergency room visits, hospital and specialist care, and imaging, lab tests, and injections performed by third parties. Patients shall also be responsible for any charges incurred for health care services provided by the practice other than covered services (anything other than remote addiction consultation and home based urine substance screening). The Practice strongly encourages the Patient to maintain health insurance during the term of this Membership Agreement to cover services that are not provided under this Membership Agreement. Patients should purchase health insurance to cover, at a minimum, unpredictable and catastrophic expenses.
4. INSURANCE. Patient acknowledges and understands that Membership in the Practice does not provide comprehensive health insurance coverage, nor is it a contract of insurance. Patient represents that patient has contacted their insurance health insurance company to discuss any limitations or restrictions that may be imposed upon patient by signing the agreement for self pay status.
A. INSURANCE CLAIMS. Patient acknowledges and understands that the Practice is not a participating provider in any Medicaid (Medi-Cal), Medicare, or private health care plan. Patient acknowledges and understands that the Practice will not bill insurance carriers on Patient’s behalf for Covered Services provided to Patient and the Practice will not bill any health care plan of which the Patient may be a subscriber or beneficiary for Membership Fees due and owing to the Practice under this Membership Agreement. Membership Fees may not be submitted to insurance companies for reimbursement.
B. TAX-ADVANTAGED MEDICAL SAVINGS ACCOUNTS. As of the date hereof, it is unlikely that the Membership Fees described in Section 2 constitute eligible medical expenses that are payable or reimbursable using a tax-advantaged savings account such as a health savings account (“HSA”), medical savings account (“MSA”), flexible spending arrangement (“FSA”), health reimbursement arrangement (“HRA”), or other health plans similar thereto (collectively referred to as a “tax-advantaged savings account”). Every health plan is uniquely different. Patients should consult with their health benefits advisor regarding whether Membership Fees may be paid using funds contained in Patient’s tax-advantaged savings account, as may be applicable.
C. HEALTH PLANS. Because the Practice is not a participating provider in any Medicaid, Medicare, or private health care plan, third party payers may not count the Membership Fees incurred pursuant to this Membership Agreement toward any deductible Patient may have under a health plan. Patients should consult with their health benefits advisor regarding whether Membership Fees may be counted toward the Patient’s deductible under a health plan, as may be applicable.
5. PRIVACY. Because payments for services are received directly between Member and Practice, the HIPAA Privacy Rule is invoked to protect patients’ medical records and other identifiable health information, also known as “protected health information” (PHI). Your record will not be shared unless
A. With Patient consent to share information with other provider. Examples include Pharmacy for medication prescription processing and payment, mental health or other referring provider, and outside addiction provider for planned transfer of care.
B. For public health. Providers can share PHI without consent if it’s necessary for public health, or if the patient is unavailable or can’t provide consent.
C. For law enforcement. Providers can share PHI to comply with state laws, such as reporting violent injuries, or to alert law enforcement if there’s a suspicion of criminal conduct.
D. For other reasons. Providers can share PHI for other reasons, such as to comply with a government investigation, to share billing information with a laboratory, ambulance service, or insurance to request prior authorization for medication.
6. TERMINATION OF AGREEMENT. Termination of this Membership Agreement shall cause the termination of Patient’s membership in the Membership Program described herein.
A. TERMINATION BY PRACTICE. The Practice may terminate this Membership Agreement upon providing Patient advance written notice. Termination will be effective starting five business days after notification. Upon termination, the Practice shall comply with all rules and regulations of the State of California Medical Board regarding the provision of emergent care for 30 days after termination and cooperate in the transfer of Patient’s medical records to the new Addiction care physician upon the Patient’s written request and direction.
B. TERMINATION BY PATIENT. Patients may terminate this Membership Agreement at any time and for any reason, upon providing advance written notice to Practice. Such termination shall be effective on the last day of the existing paid membership period. Membership Fees shall not be prorated for any terminal period (i.e., no refunds will be provided for unused services). Membership Fees will continue to accrue until Patient’s written notice of termination is received by practice.
7. REINSTATEMENT. Patients will require an Initial Registration Consultation to reenter or resume “membership services” if there is more than 90 days disruption of membership service. I.e. Patient pays and scheduled Initial Registration consultation (six hundred dollars, $600)
8. INDEMNIFICATION. Patient agrees to indemnify and to hold the Practice and its members, officers, directors, agents, and employees harmless from and against all demands, claims, actions or causes of action, assessments, losses, damages, liabilities, costs and expenses, including interest, penalties, attorney fees, etc. which are imposed upon or incurred by the Practice as a result of the Patient’s breach of any of Patient’s obligations under this Agreement.
9. ENTIRE AGREEMENT. This Membership Agreement constitutes the entire understanding between the parties hereto relating to the matters herein contained and shall not be modified or amended except in a writing signed by both parties hereto.
10. WAIVER. The waiver of either the Practice or Patient of a breach of any provisions of this Membership Agreement must be in writing and signed by the waiving party to be effective and shall not operate or be construed as a waiver of any subsequent breach by either the Practice or Patient.
11. CHANGE OF LAW. If there is a change of any law, regulation or rule, federal, state or local, which affects this Membership Agreement, any terms or conditions incorporated by reference in this Membership Agreement, the activities of the Practice under this Membership Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and the Practice reasonably believes in good faith that the change will have a substantial adverse effect on the Practice’s rights, obligations or operations associated with this Membership Agreement, then the Practice may, upon written notice, require the Patient to enter into good faith negotiations to renegotiate the terms of this Membership Agreement. If the parties are unable to reach an agreement concerning the modification of this Membership Agreement within ten (10) days after the effective date of change, then the Practice may immediately terminate this Membership Agreement upon providing written notice to the Patient.
12. GOVERNING LAW. This Agreement and the rights and obligations of the Practice and Patient hereunder shall be construed and enforced pursuant to the laws of the State of California.
13. ASSIGNMENT/BINDING EFFECT. This Membership Agreement shall be binding upon and shall insure to the benefit of both the Practice and Patient and their respective successors, heirs and legal representatives. Neither this Membership Agreement, nor any rights hereunder, may be assigned by the Patient without the written consent of the Practice.
IN WITNESS WHEREOF, the parties have caused this Membership Agreement to be effective on the Effective Date first above written between
Addiction Change Experts (ACE) Medical Inc, a California Medical Professional corporation and
Patient Name ______________________________________
Patient Signature _____________________________
Date Signed ______________________
Refunds
There are no refunds for membership fees if the services are not used. If the Consultation practice is closed for reasons other than bankruptcy during paid membership, a pro-rated refund will be processed, and a credit will be returned minus any administrative fees to the original method of payment, within 30 days of practice closing.
Shipping Costs:
Home based Urine Drug Screening will be included in the cost of your membership. Cost of shipping is included in your membership. Frequency of Drug screening will be determined with your consultation.
Depending on where you live, the time it may take for your home urine drug testing supplies to arrive.
You may discard unused or expired Urine drug tests if your membership service agreement has expired
Need help?
Contact us at ChooseChange@ACEMedical.biz for questions