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Terms and Conditions

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Welcome to We The People Health and Wellness Center! We are delighted to have you as a potential member of our direct primary care center. Our Membership Consultant will be reaching out to you within 24 hours to secure an appointment with you. Before proceeding, please take a moment to read and understand our terms and conditions outlined below:

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1. Membership and Registration Fee:
By paying the registration fee stated on our website under the pricing tab, you agree to become a member of We The People Health and Wellness Center. This fee is nonrefundable, and its purpose is to secure your membership and access to our services.

2. Residency Requirement:
To be eligible for membership, you must be a resident of the state of Florida. Proof of residency may be required during the registration process.

3. Membership Completion:
As a member, it is necessary for you to complete your membership, consultation, and package within 30 days of the launch date specified on our website. Failure to do so may result in the cancellation of your membership without refund.

4. Membership Pricing:
The price for membership is clearly listed on our website under the pricing tab. By proceeding with the payment, you acknowledge and agree to the specified pricing.

5. Refund Policy:
We understand that circumstances may change, and therefore offer a refund option for the registration fee under certain conditions. If you wish to receive a refund of your $150 registration fee, you must contact us within 24 hours of submitting the payment. Refund requests made after this time frame will not be considered.

Please note that the refund policy only applies to the registration fee, and membership fees are nonrefundable. Refunds will be issued through the original payment method, and any associated transaction fees will be deducted from the refunded amount.

6. Contact Information:
For any questions, concerns, or refund requests, please contact us at [insert contact details: email address or phone number]. We are here to assist you and provide further clarification.

By continuing with the registration process and submitting the payment, you acknowledge that you have read, understood, and agreed to the terms and conditions stated above. We are excited to have you join our health and wellness center and look forward to providing you with excellent care and service.

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Copy of Membership Agreement which will be provided at the time of consultation:

Patient Agreement

We The People Health and Wellness Center

 

This is an Agreement between We The People Health And Wellness Center, LLC, a Florida limited liability company (“Practice” or “WTP Healthcare”), located at 959 E. Venice Ave, Venice, Florida 34285, and                                                                                                                (the “Patient” or “You”). If the Patient is under 18 years of age, this Agreement shall be signed by the parent or guardian of the Patient or such other adult with authority to consent to treatment on behalf of the Patient in accordance with Sections 743.0645 and 1014.06 of the Florida Statutes. This Agreement is intended to be a direct health care agreement for purposes of Florida Statutes and is not an agreement for insurance or other healthcare coverage subject to the Florida Insurance Code.

 

Background

 

The Practice is a direct-pay family practice that provides comprehensive primary care services through its physicians, physician assistants, advance practice registered nurses or other health care providers employed or contracted with the Practice (collectively, the “Provider”), to its patients on an ongoing basis for acute, chronic and wellness issues through a membership-based direct primary care model, at 959 E. Venice Ave, Venice, Florida 34285. As the Patient or as the parent or legal guardian of the Patient(s) enrolled under this Agreement, You agree to pay certain fees in exchange for the provision of certain medical and non-medical services which are described herein.  Additional information regarding the Practice, Providers and the Services they provide can be found on the Practice’s website at www.wtphealthcare.com.

 

Terms and Conditions of this Agreement

1. Definitions

 

1. “Patient” is defined as those persons for whom the Provider shall provide Services, and who is a signatory to, or whose parent or guardian are signatories to, or listed on the documents attached as Appendix 1, and incorporated by reference, to this Agreement.

 

1. “You” means the Patient or the Party to this Agreement who is the Parent, Guardian, or other authorized adult of the Patient(s) listed herein, and who has executed this Agreement.

 

1. “Services” means the delivery of ongoing care services described in Appendices 1 and 2 by the Practice and its Providers.

 

1. Services. As used in this Agreement, the term Services, shall mean a package of ongoing  medical and non-medical services, and certain amenities (collectively, “Services”), which are offered by the Practice and set forth in more detail in Appendices 1 and 2, attached.  You and Patient will be provided with methods to contact the Provider via secure text, secure email, video and other methods of electronic communication.  Provider will make every effort to be available at all times via phone, email, other methods such as “after hours” appointments when appropriate, but Provider cannot guarantee 24/7 availability. Provider cannot guarantee that the Patient will not need to seek treatment in an urgent care or emergency department setting.

 

1. Fees. In exchange for the services described herein, You agree to pay Practice the amounts as set forth in Appendices 1 and 2, attached.  If You elect to pay all fees on a monthly basis, You will pay fees monthly in advance on or before the 1st day of each month.  If You elect to pay all fees on an annual basis, You will pay the annual fee as of the date of this Agreement and on each anniversary date thereof. If You elect to pay all fees on an annual basis and terminate this Agreement prior to an anniversary date, the Practice shall return a prorated portion of such fees to You. Practice may adjust its fees at any time.  Practice will give You at least 30 days advance notice of any changes in monthly fees. Laboratory tests, prescription drugs and other services provided by Practice, and which are charged to You and Patient in addition to monthly fees may be changed from time to time and will be posted on Practice’s website.  Practice will not charge or receive any fee from You, other than as set forth in this Agreement, for Services that are described in this Agreement.

 

1. Non-Participation in Insurance. You acknowledge and understand that neither Practice, nor the Provider participates in or contracts with Medicare or any health insurance plans, including, but not limited to, Health Maintenance Organizations (HMO) plans, Point of Service Plans, Preferred Provider Organizations, Preferred Provider Networks. [However, Provider is currently opted in with Medicare.]

 

You acknowledge and understand that federal regulations REQUIRE that Provider opts out of Medicare so that Medicare patients may be seen by the Practice pursuant to this Agreement. Neither the Practice nor Provider makes any representations regarding third party insurance reimbursement of fees paid under this Agreement.You shall retain full and complete responsibility for any such determination. Patient specifically acknowledges and agrees that Patient is not currently eligible for Medicare and if during the term of this Agreement becomes eligible for Medicare, Patient agrees to immediately notify Practice and this Agreement shall automatically terminate.

 

You further acknowledge that the Practice does not accept Medicare and, pursuant to federal regulations, the Practice cannot currently receive payment on behalf of patients with Medicare coverage. If the Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, [ - []

 

You further acknowledge that the Practice does not accept Medicaid and the Practice cannot currently receive payment on behalf of patients with Medicaid coverage.You specifically acknowledge and agree that Patient is not currently a Medicaid recipient and if Patient become a Medicaid recipient in the future, You agree to immediately notify Practice and this Agreement shall automatically terminate.

 

You acknowledge and understand that the Practice and Provider will not seek reimbursement from Medicare, Medicaid or any other health insurance plans and as a result, Medicare, Medicaid or any such health insurance plans cannot be billed for any services performed for You by the Provider. You agree not to bill Medicare, Medicaid or any federal health insurance plan or attempt Medicare, Medicaid, or any federal health insurance plan reimbursement for any such services.

 

1. Insurance or Other Medical Coverage. You acknowledge and understand that this Agreement is not an insurance plan and is not a substitute for health insurance or other health plan coverage (such as membership in an HMO). It will not cover hospital services, or any services not personally provided by Practice or its Providers. You acknowledge that Practice has advised that You obtain or keep in full force such health insurance policy(ies) or plans that will cover Patient for hospitalization and general healthcare costs. You acknowledge that this Agreement is not a contract that provides health insurance.  This Agreement does not meet the insurance requirements of the Affordable Care Act and is not intended to replace any existing or future health insurance or health plan coverage that Patient may carry.  This Agreement is for ongoing medical care, and the Patient may need to visit the emergency room or urgent care from time to time or obtain healthcare services, such as diagnostic tests, from other healthcare providers. You understand that the Practice will NOT submit any claims for Services to your insurance plans on behalf of the Patient, and that You will be solely responsible for submitting such claims if You choose to seek reimbursement from an insurance plan for such Services.  You further understand that any reimbursement by any insurance plan will be sent directly to You, and that You will be responsible for seeking reimbursement from your insurance or otherwise paying for all healthcare provided by anyone other than Practice or Provider to Patient.

 

1. Term, Renewal & Termination. This Agreement shall commence on the date it is signed by parties below and shall continue for a period of one month and shall automatically renew for successive monthly terms upon payment of the monthly fee at the end of the contract month. If You elect to pay all fees hereunder as one annual payment, the Agreement shall continue for a period of one year and automatically renew for successive one-year terms. Notwithstanding the above, both Patient and Practice shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination, upon  giving thirty (30) days prior written notice to the other Party.  The Practice may terminate the Agreement at any time without cause by providing thirty (30) days prior written notice, except for the circumstances of immediate termination below, to You and shall assist the Patient with identifying alternative healthcare providers as required by law and Provider’s ethical duties.  Examples of reasons the Practice may wish to terminate the agreement with the Patient may include but are not limited to:

 

1. You fail to pay applicable fees owed pursuant to Appendix 1 and 2 per this Agreement;

2. The Patient repeatedly fails to show for scheduled appointments;

3. The Patient repeatedly fails to adhere to the recommended treatment plan, especially regarding the use of controlled substances;

4. You or the Patient is physically or emotionally threatening to Provider or other patients or staff members;

5. The Provider determines that the clinical relationship between Patient and Provider cannot continue; or

6. Practice discontinues operation.

 

Practice may immediately terminate this Agreement upon a patient’s violation of the Provider-Patient relationship or a breach of the terms of this Agreement.  Practice has a right to determine whom to accept as a patient.

 

1. Privacy & Communications. You acknowledge that communications with the Provider using e-mail, facsimile, video chat, instant messaging, and cell phone are not guaranteed to be secure or confidential methods of communications.  The Practice will try to promote the utilization of the most secure methods of communication, such as software platforms with data encryption and to secure all communications via passwords and other protective means.  However, other, less secure, means of communications may be available to You and the Patient.  If You initiate a conversation in which You or the Patient discloses “Protected Health Information” or other confidential consumer information (such as medical conditions, billing information or other identifiers) on one or more of these communication platforms, such as by email or text message, then You have authorized the Practice to communicate with You and the Patient regarding these matters in the same format.

 

1. Technical Failure. Neither the Practice nor its staff will be liable for any loss, injury, or expense arising from a delay in responding to You or the Patient when that delay is caused by technical failure. Examples of technical failures: (i) failures caused by an internet or cell phone service provider; (ii) power outages; (iii) failure of electronic messaging software, or email provider; (iv) failure of the Practice’s computers or computer network or faulty telephone or cable data transmission; (v) any interception of email communications by a third-party which is unauthorized by the Practice; or (vi) Your or Patient’s failure to comply with the guidelines for the use of email or text messaging, as described in this Agreement.

 

1. Provider Absence. From time to time, due to such things as vacations, illness or personal emergency, the Patient’s preferred Provider may be temporarily unavailable. When the date(s) of such absences are known in advance, the Practice shall give notice to You so that You may schedule non-urgent care accordingly. During unexpected absences, Patients with scheduled appointments shall be notified as soon as practicable, and appointments shall be rescheduled at the Patient’s convenience or the patient may see an alternate Provider, if one is available. If during the Patient’s preferred Provider’s absence, the Patient experiences an acute medical issue requiring immediate attention, the Patient should proceed to an urgent care or other suitable facility for treatment. Charges from any such other outside provider are the Patient’s responsibility and are not included in this Agreement. Patient may submit such charges to Patient’s insurance or request the outside provider to do the same, but we cannot guarantee insurance reimbursement.

 

1. Dispute Resolution. Each party agrees not to make any inaccurate or untrue disparaging statements, oral, written, or electronic, about the other. We strive to deliver only the best of personalized patient care to every Patient, but occasionally, misunderstandings arise. We welcome sincere and open dialogue with our Patients, especially if we fail to meet expectations, and we are committed to resolving all Patient concerns. Therefore, if You or Patient is dissatisfied with, or has concerns about, any staff member, service, treatment, or experience arising from their membership in the Practice, You, Patient, and Practice agree to refrain from making, posting or causing to be posted on the internet or any social media, any untrue, unconfirmed, inaccurate, disparaging comments about the other. Rather, the parties agree to engage in the following process:

 

1. You shall first discuss any complaints, concerns or issues with Provider;

2. Provider shall respond to each of Your or the Patient’s issues and concerns;

3. If, after such response, You remain dissatisfied, the parties shall enter into discussion and attempt to reach a mutually acceptable solution.

 

1. Change of Law. If there is a change of any relevant law, regulation or rule, federal, state, or local, which affects the terms of this Agreement, the parties agree to amend this Agreement to comply with the law.

 

1. 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.

 

1. Amendment. Except as provided within, no amendment of this Agreement shall be binding on a party unless it is in writing and signed by all the parties.

 

1. Reimbursement for Services if Agreement is Invalidated. If this Agreement is held to be invalid for any reason, and if Practice is therefore required to refund all or any portion of the monthly fees paid by You, You agree to pay Practice an amount equal to the fair market value of the Services rendered to Patient during the period of time for which the refunded fees were paid.

 

1. Assignment. This Agreement, and any rights You or Patient may have under it, may not be assigned or transferred by You.

 

1. Entire Agreement. This Agreement contains the entire Agreement between the parties and replaces any earlier understandings and agreements, whether they are written or oral. All Exhibits and Appendices to this Agreement, either as originally existing or as the same may from time to time be supplemented, modified or amended, are incorporated herein by this reference.

 

1. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Florida and all disputes arising out of this Agreement shall be settled in a Florida state court of proper jurisdiction sitting in Sarasota County,  Florida.

 

1. The Hippocratic Oath. Providers have sworn an oath to provide the best treatment available to their patients. Their recommendations are based on scientific evidence and guidelines put forth after intense study by various health institutes. The Provider will promote a collaborative relationship with Patient, but the Provider will not offer treatments that the Provider deems to be not medically indicated or that may result in harm to the Patient, as determined by Provider in Provider’s best medical judgment.  

 

1. Patient Understandings (to be initialed by You on behalf of Patient):

 

_______          This Agreement is for ongoing medical care and is not a medical insurance agreement.

 

_______          I give my written consent to the Practice to provide medical care services to the Patient, as indicated by my signature hereto.

 

_______          I understand and consent to the prescription of any medications the Practice deems necessary for the treatment of the Patient.

 

_______          I understand that I am responsible for paying the monthly fees and other costs in this Agreement, and that if I do not pay the fees required, this Agreement will terminate, and Practice will no longer provide medical care services.

 

_______          I acknowledge that this Pediatric Patient is not a Medicaid recipient or a Medicare beneficiary, and I agree to immediately notify Practice if this status changes. (Initial only if You are signing as the parent of a minor Patient).

 

_______          The Patient does not have an emergent medical problem at this time.

 

_______          In the event of a medical emergency, I agree to call 911 first or seek care at an emergency room or other appropriate location.  I understand that Provider and the Services provided under this agreement are not intended to include emergency medical care.

 

_______          I do not expect the Practice to file or fight any third-party insurance claims on my behalf.  I will not submit any claims to third-party insurers for services I receive from the Practice, whether on an out-of-network basis or otherwise.

 

_______          I understand that I will be responsible for all costs of healthcare services received outside of the Practice, either on my own or through health insurance that I maintain.  This includes costs of pharmaceuticals prescribed to the Patient by the Provider and filled at any third-party pharmacy (i.e., SaveSmart, CVS or Walgreens), or other treatments or tests recommended to the Patient by Provider that I cannot obtain at the Practice.

 

_______          I understand that Practice only prescribes chronic controlled substances in extremely limited circumstances, and only when the Provider feels they are clinically indicated and there are no other medically sound alternative.  (Chronic controlled substances include things such as commonly abused non-opioid medications like Tramadol, benzodiazepines, and sleep aids.) 

 

_______           In the event I have a complaint about the Practice, I will first notify the Practice directly and allow the Practice an opportunity to address my concern. 

 

_______          I am enrolling the minor or ward, for whom I sign below as guardian, as a Patient in the Practice voluntarily. (Initial only if You are signing as the parent of a minor Patient).

 

_______          I may receive a copy of this document upon request.

 

_______          This Agreement is non-transferable.

 

_______          I understand that I must pay for each membership month with an auto-deduct option on a valid credit or debit card. This will be auto deducted on the last day of the month prior to the month that is being paid for. Otherwise I will be billed on a yearly basis. If I have not paid my membership fee for a given month, I will not be able to access any services unless I pay the cash fee for a non-member visit to the Practice. I authorize the Practice to automatically charge my credit card or debit card for the monthly fee. 

 

_______          I UNDERSTAND THAT THIS AGREEMENT IS NOT HEALTH INSURANCE, IS NOT SUBJECT TO THE INSURANCE LAWS OF THE STATE OF FLORIDA, AND DOES NOT MEET ANY INDIVIDUAL HEALTH INSURANCE MANDATE THAT MAY BE REQUIRED UNDER STATE AND/OR FEDERAL LAW.

 

 

 

 

 

 

 

 

 

 

 

 

This agreement is not health insurance and the health care provider will not file any claims against the patient’s health insurance policy or plan for reimbursement of any health care services covered by the agreement. This agreement does not qualify as minimum essential coverage to satisfy the individual shared responsibility provision of the Patient Protection and Affordable Care Act, 26 U.S.C. s. 5000A. This agreement is not workers’ compensation insurance and does not replace an employer’s obligations under chapter 440.

 

 

Patient Name: __________________________________________________________

 

Patient (or Guardian) Signature*__________________________________ Date: ___________

 

Patient (or Guardian) Signature*__________________________________ Date: ___________

 

 

*If signature is by a guardian on behalf of a minor or ward, please indicate the nature of your relationship and attach the Court's appointment letter. If signing as the parent of a minor, please provide contact information for both parents, and either confirm that there are no Court orders impacting each parent's ability to give consent OR attach Court's letter designating which parent has the right to consent for medical care and any limitations.

We The People Health And Wellness Center, LLC

 

WTPHC Membership Representative: (print name) ____________________________________

 

Signature: ______________________________________  Date:  ________________________

 

 

Approved By:

 

_______________________________________________

Tanya Parus

President/Managing Member

 

 

 

 

 

 

 

APPENDIX 1

Fee Schedule

 

This Agreement is for ongoing primary care.  This is Agreement is not health insurance and Practice 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, and You will be responsible for all such charges.  Each Provider within the Practice will make an appropriate determination about the scope of medical care services offered by the Physician.  Examples of common conditions we treat, procedures we perform, and medications we prescribe are listed on our website and are subject to change. 

 

1. Registration Fees

 

Per Member (any plan) - $150

 

Per Family Plan - $____________________   Other:  _____________________________

 

1. Reenrollment Fees  This is charged at the time of the Patient’s first visit with the Practice and is nonrefundable.  This fee is subject to change.  If a patient discontinues membership and wishes to re-enroll in the Practice, we reserve the right to decline re-enrollment or to require that the re-enrollment fee be $ 150.00

 

1. Periodic Fees  The Periodic Fees  (membership plan)is for ongoing medical care services. All in-office and virtual visits are included in the fee. Some ancillary services will be passed through as additional charges based on the prices we negotiate with third-party service providers. Examples of these ancillary services include certain laboratory testing and dispensed medications.  These are described in Appendix 2.  Many services available in our office are available at no additional cost to you. Items available at no additional cost will be listed on our website and are subject to change. 

 

The monthly Periodic Fee (membership plan) for the Practice’s Plans are as follows (select your choice(s)):

 

• IV Therapy ($_________/month)

• Freedom Start ($70/month)                           

• Freedom Growth A ($70/month)

• Freedom Growth B (50/month)

• Freedom Prime ($80/month) 18-44 yrs. old

• Freedom Vitality ($100/month) 45-64 yrs. old

• Freedom Legacy ($160/month) 65+

• Family Plan ($240/month) 2 adults and 2+ children

• Other __________________

 

 

 

Total Monthly Periodic Fee is $__________________. Billing start date:  ________________

 

Membership Payment Terms.  Practice provides monthly and annual payment options. All payments are automatically deducted on the last day of the month (prior to the month that is being paid for) or year on the date of enrollment. Payments will be automatically deducted by Practice from a valid credit or debit card. Patient agrees to notify Practice of any changes in payment information.

 

Annual Fee Payment Discounts Notwithstanding the foregoing, if You elect to pay the monthly fee for a twelve (12) month period in full at the time of enrolling with the Practice, the Patient shall be entitled to a 5% discount to such amount.  Please note such discount will be applied as a monthly periodic fee due during the initial term of enrollment with the Practice.  In the event Patient terminates enrollment with Practice prior to the completion of the one year term period, Patient will forfeit any and all applied discounts and incentives provided by Practice under this Agreement. All outstanding Patient’s fees and other amounts due from Patient will be collected by Practice, if any. Any remaining amount of the monthly fees paid in advance shall be refunded to the Patient.

 

If this Agreement is cancelled by either party before the Agreement term ends, we will review and settle your account as follows:

 

1. You will retain access to the Services during the month You have paid through. Example, if you paid April 1st and terminate services April 15th, you will have access to services through April 30th. Your April dues will not be pro-rated back to you.

2. If You have paid annually, you will be prorated back the funds for the unused months. Example, if you paid a year in full January 1st and terminate services April 15th, you will have access to Services through April 30th and will be refunded May - December’s fees.

3. If Value of the Services you received over the term of the Agreement exceeds the amount You paid in membership fees, you shall reimburse Practice in an amount equal to the difference between the value of the services received and the amount You paid in membership fees over the term of the Agreement. The Parties agree that the value of the services is equal to the Practice usual and customary fee-for-service charges. A copy of these fees is available on request. Example: if Patient paid a year in full on January 1st ($1200 total) and decides to terminate their membership effective March 31st, he or she can do so with 30 days prior written notice to the Practice (March 1). After termination, it is determined that the Patient utilized services six times ($50/each service), including 2 free IV Therapy sessions ($150/each session) included in the annual membership.  As a result, the Patient will reimburse Practice for the value of six visits ($300) plus the value of the two IV therapy sessions ($300) minus the 3-month membership fees ($300) (total amount due by Patient $300). Practice will reimburse Patient in the amount of $600 (April – December prepaid fees ($900) less $300 owed by Patient to Practice). Please note the amount listed above are for illustrative purposes only.

 

1. Cancellation Fees If a Member does not show for a scheduled appointment or provide at least 24-hour notice of cancellation, a $50 fee will apply for each missed appointment.

 

1. Acceptance of Patients  We reserve the right to accept or decline patients based upon our capability to appropriately handle the patient’s medical care needs.  We may decline new patients pursuant to the guidelines proffered in Section 6 (Term), because the Provider’s panel of patients is full, because the patient requires medical care not within the Provider’s scope of services, or for any other reason at the discretion of Practice and Provider.

 

APPENDIX 2-A

 

Direct Primary Care Medical & Non-Medical Services

 

Adult Primary Care Services

 

At We The People Health & Wellness Center, we are committed to providing personalized care that is focused on your individual health needs. 

 

We The People isn’t just a center for health care, it’s a health home - offering a true patient-doctor relationship.  It is about being connected with our patients and spending the time needed for education.  Understanding your health and how to better yourself is key.

 

1. Medical and Non-Medical Services included in Membership Fee:

1. In-Office

2. Telehealth/Virtual (established patients) some services not available with telehealth/virtual visits

3. Annual, In-Depth Wellness Evaluation. Available by appointment once every 12 months and includes updated history, physical exam, exercise & dietary plan

4. Acute Care Visits. Short-term medical care designed to deliver rapid evaluation and management of injuries, acute and chronic pain, episodes of sickness and illness or urgent medical conditions.

5. Foreign Body Removals. Foreign body removal (skin, ears, nose), wart removals, Incision and drainage of skin abscesses,

6. Communication. For non-urgent communication Member(s) shall contact the Practice via email at membership@wtphealthcare.com. Such communications shall be answered in a timely manner not to exceed 72 hours from receipt. Member(s) understand and agree that email and the internet should never be used to access emergency medical care. Members experiencing a medical emergency must dial 9-1-1 or go to the nearest emergency room.

7. Access. Members are welcome to obtain Services without a prior appointment at any time during normal business hours, and at any location of the Practice, except for annual health assessment visits. Annual health assessments must be scheduled by appointment only. Members are encouraged to arrive at least 1 hour prior to closing for non-scheduled visits.

8. Coordination of Care. If Member(s) requires the care of a medical professional outside the scope of this Agreement (a “Specialist”), the Practice or its Providers will provide, if possible, the Member(s) with contact information for, and assist Member(s) in obtaining an appointment with, a Specialist. Member(s) understand and agree that Fees paid under this Agreement do not include the services of Specialists.

9. Other Services

• Comprehensive and compassionate care for every patient we see.

• Regular physical exams and check-ups for monitoring overall health.

• Small suturing, determined by health care provider.

• Management of chronic conditions such as high blood pressure, diabetes, and heart disease.

• Screenings for common health issues such as cancer and depression.

• Hospital advocacy by phone or telehealth visits — with additional Patient Advocacy Plan

• Women’s health services breast exams, hormone discussions and testing and family planning services.

• Guidance on healthy lifestyle habits such as exercise, nutrition, and stress management.

• Referrals to other healthcare providers or specialists for specialized care.

• Health education and disease prevention strategies.

• Prescriptions at discounted cost with our preferred pharmacists

• Guidance on healthy eating habits and weight management.

• Individual mental health counseling & group sessions  

• Hospital advocacy by phone or telehealth visits ——we will help you understand questions that you might be asking & support your family during your child’s hospitalization.

  • Additional advocacy may be needed (case dependent) and will be discussed with guardian if beyond the scope of provided care

• Complimentary access to any support group or seminars or classes issued by the practice

• An emphasis on keeping you healthy 

• Care for simple wounds, simple lacerations (case by case determined) infections, and minor burns

• Management of acute strains and sprains

• Individual mental health counseling & group sessions  

• Lavage and removal of cerumen (ear wax)

• Nebulizer treatments for respiratory issues (within office hours, as determined by the provider)

• Joint, tendon, or trigger-point corticosteroid injections

  • One series included within the year

  • Additional $200/each

• Some liquid nitrogen cryotherapies of actinic keratoses treatments

  • Determined by the provider

• 2 Complimentary Hydration IV’s under $200 each

• 20% Discount on all IV’s and IM injections- Including IV Therapy Memberships

• EKG (in-office) as determined by the provider

 

1. Services Provided at a Discounted Cost. The following services are offered by the Practice at discounted rates to Members and are not included in the Membership Fees (except as shown for first time application).  A complete list of discounted rates is available to Members on our website or upon request.

 

1. Surgical Procedures & Supplies                                       $175

   1. Cryotherapies                                                              Range from $50-$200

2. IV Hydrations, Infusion of Medications                           $ Price varies

3. Joint Aspirations, Injections of Medication                     $ 200

4. Fracture Treatment, Casting, Splinting & Supplies         $ 100 if able to provide

5. X-ray Imaging                                                                  Not provided

6. Ultrasound Imaging                                                          Not provided

7. CT Imaging                                                                       Not provided

8. Durable Medical Equipment                                            Cost varies

9. Labs- See below (testing is performed by Lab-Corp at their location, unless specifically noted)

 

 

LABS - Blood analysis testing is performed, unless specifically noted, by Lab-Corp at their location.

 

• Basic Metabolic Panel- This test measures levels of electrolytes, glucose, and kidney function. It can help identify issues such as dehydration and kidney problems.

  • One panel included per year-additional $25

 

• Vitamin D, 25-Hydroxy – Measures the level of your Vitamin D in your blood stream Vitamin D isa nutrient that is important for bone health, immune function, and other bodily processes.

  • One test included per year-additional $55

 

• Lipid Panel With LDL/HDL Ratio and review- measures different types of fats in your blood. The test tells you your total cholesterol, triglycerides, LDL (bad) cholesterol, and HDL (good) cholesterol.

  • One test included per year-additional $25

 

• Lipid Panel and Chol/HDL Ratio and review- The LDL and HDL ratio is calculated by dividing the LDL cholesterol level by the HDL cholesterol level. This test helps doctors assess your risk of developing heart disease and monitor the effectiveness of cholesterol-lowering treatments.

  • One test included per year-additional $25

 

• Thyroid Stimulating Hormone (TSH): This test measures thyroid function and can help identify thyroid disorders.

  • One test included per year

  • additional $25

 

• Urinalysis: This test examines a sample of urine and can help identify urinary tract infections, kidney problems, and other issues. (as needed and determined by the provider)

  • included in office visit

 

 

• Urine Pregnancy Testing

  • included in office visit

• Glucose

  • included in office visit

• COVID Testing

  • One rapid test included in office visit

  • additional $10

• Rapid test for Group A Strep

  • included in office visit

• Fecal Occult Blood Testing- FOBT - medical test that is used to detect small amounts of blood in the stool that are not visible to the naked eye. The test is designed to screen for early signs of colon cancer, as well as other conditions that can cause bleeding in the digestive tract, such as ulcers, hemorrhoids, and inflammatory bowel disease.

  • One test included per year

  • Additional $25 (as needed and determined by the provider)

• Mononucleosis testing

  • One test included per year

  • additional $25

• Rapid test for Group A Strep

  • included in office visit

• COVID Testing

  • One rapid test included in office

  • additional $10

           

 

APPENDIX 2-B

 

Direct Primary Care Medical & Non-Medical Services

 

Pediatric Primary Care Services

 

At We The People Health & Wellness Center, we are committed to providing personalized care that is focused on your individual health needs. 

 

Services included:

In-Office

Telehealth/Virtual (established patients) – note that some services are not available with telehealth/virtual visits

• Access to pediatrician; telehealth, phone, text, or email -triage incoming calls may be handled by another provider before reaching the pediatrician.

• We try our best to get you a same or next day appointments (after hours appointments are usually available when necessary and determined through triage)

• Comprehensive and compassionate care for every child we see with parents in full control of health care decisions after informed consent discussions.

• Regular physical exams and check-ups for monitoring growth and development ages birth through 18

• Wellness visits

• Acute visits

• Sick visits for when children are not feeling well.

• Evaluations for developmental and behavioral concerns including Autism, ADHD, Motor and Speech Delays

• Regular physical exams and check-ups for monitoring growth and development ages birth through 18. Including newborn weight and growth checks.

• Hearing and vision screenings.

• Wart removals

• Sports physicals and exams required by schools and camps.

• Discussions and guidance about behavioral issues & other common parental concerns

• Annual, in-depth wellness evaluation; includes exercise & dietary plan

• Prescriptions at discounted cost with our preferred pharmacists

• Guidance on healthy eating habits and weight management.

• Care coordination with specialists as needed

• Management of chronic conditions such as asthma 

• Referrals to other healthcare providers or specialists for specialized care.

• Individual mental health counseling & group sessions  

• Hospital advocacy by phone or telehealth visits ——we will help you understand questions that you might be asking & support your family during your child’s hospitalization.

  • Additional advocacy may be needed (case dependent) and will be discussed with guardian if beyond the scope of provided care

• Access to any support group or parenting classes  issued by the practice

• An emphasis on keeping your child healthy 

• Care for simple wounds, simple lacerations (case by case determined) infections, and minor burns

• Management of acute strains and sprains

• Individual mental health counseling & group sessions  

• Foreign body removal (skin, ears, nose)

• Lavage and removal of cerumen (ear wax)

• Incision and drainage of skin abscesses

• Nebulizer treatments for respiratory issues (within office hours)

LABS - All labs unless specifically noted, to be performed by Lab-Corp at their location.

 

• Urinalysis: This test examines a sample of urine and can help identify urinary tract infections, kidney problems, and other issues. (as needed and determined by the provider)

  • included in office visit

 

• Urine Pregnancy Testing

  • included in office visit

• Glucose

  • included in office visit

• COVID Testing

  • One rapid test included in office visit

  • additional $10

• Rapid test for Group A Strep

  • included in office visit

• Fecal Occult Blood Testing- FOBT - medical test that is used to detect small amounts of blood in the stool that are not visible to the naked eye. The test is designed to screen for early signs of colon cancer, as well as other conditions that can cause bleeding in the digestive tract, such as ulcers, hemorrhoids, and inflammatory bowel disease.

  • One test included per year

  • Additional $25 (as needed and determined by the provider)

• Mononucleosis testing

  • One test included per year

  • additional $25

• RSV Testing

  • One rapid test included in office

  • additional $10

 

 

 

 

 

 

 

APPENDIX 3

 

Direct Primary Care Informed Consent and Agreement for Telehealth Services

 

Consent to Telehealth

 

I understand that providing my signature, handwritten or in electronic format of any kind, on this document constitutes my legal signature on behalf of the minor or ward for whom I sign below as parent or guardian. In providing my signature on this document, in any form, I am confirming that I understand and agree to its terms.

 

Definition of Telehealth

 

For the purposes of this document, Telehealth is defined as the electronic communications technologies used by my Provider and staff at, We The People Health and Wellness Center, LLC (“Practice”), to enable them to obtain information and communicate remotely in order to provide patient care. I understand that the same standard of care applies to medical treatment obtained through telehealth communications as applies to an in-person visit. This information obtained through telehealth communications may be used to diagnosis, treatment, follow-up and/or education, and may include any of the following:

 

Patient medical records

• Medical images

• Live two-way audio and video and data communications

• Output data from medical devices and sound and video files

• Questionnaires, email and text messaging

 

The electronic systems used will incorporate network and software security protocols to protect confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

 

Understandings

 

I understand that:

• Telehealth involves the communication of my child, minor, or ward’s health information in an electronic or technology-assisted format.

• All electronic medical communications carry some level or risk.

• Despite reasonable security efforts, electronic communication can be forwarded, intercepted, or changed without my knowledge.

• Electronic systems that are accessed by employers, friends or others are not secure and should be avoided.

• It is important for me to use a secure network.

• Despite reasonable efforts on the part of my Provider, the transmission of medical information could be disrupted or distorted by technical failures.

• I may opt-out of the telehealth visit at any time.

• The Practice will maintain information exchanged during my child, minor, or ward’s telehealth visit as part of my medical record.

• Neither the Practice nor my Provider is responsible for breaches of confidentiality caused by an independent third-party or by myself or my child, minor, or ward.

• I must verify my identity and current location to my Provider and failure to do so may terminate the telehealth visit.

• Electronic communication cannot be used for emergencies or time-sensitive matters.

• I understand that electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependence, etc.).

• A medical evaluation via telehealth may limit my Provider’s ability to fully diagnose a condition or disease. As the parent or guardian of the Patient, I agree to accept responsibility for following my Provider’s recommendations – including further diagnostic testing, such as lab testing, a biopsy or an in-office visit.

• There is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when medical care is provided.

• By electronically signing, I am certifying that I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit.

 

Possible Benefits of Telehealth

 

• Easier access to medical care

• Convenience

• More time efficient medical evaluation and management

 

Possible Risks of Telehealth

 

As with any technology used in medical care, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

 

• Information transmitted may not be sufficient to allow for appropriate medical decision making by the Provider.

• Provider may not be able to provide medical treatment for your conditions remotely.

• Regulatory and other requirements may limit Provider’s ability to provide certain treatment options, including prescriptions.

• Delays in medical evaluation and treatment could occur due to deficiencies or failures in technology equipment.

• Security protocols could fail, resulting in privacy breaches of personal medical information.

 

I certify, by signing below, that I have read and understand this informed consent document. I have had the opportunity to have any of my questions answered so that I understand this document in its entirety, and I request and give my consent to participation in telehealth on behalf of the minor or ward for whom I sign below as parent or guardian. I understand that I may receive a hard copy of this informed consent upon request.

 

Patient Name:  __________________________________________________

 

Date:  ______________________________

 

Patient (or Guardian) Signature          _____________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTICE OF PATIENT PRIVACY PRACTICES

 

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (OR AS THE PARENT OR GUARDIAN OF A PATIENT WHO IS A MINOR OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GAIN ACCESS TO INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.

 

1. OUR COMMITMENT TO YOUR PRIVACY:

 

We The People Health and Wellness Center, LLC

 

PATIENTS UNDER 18 YEARS OF AGE: As a parent/legal guardian of a minor patient at Practice, You are the patient’s “personal representative.” When reading this Notice please understand that when we use the term “You” or “you” we mean the patient. The Practice is dedicated to maintaining the privacy of your personally identifiable, PHI. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We strive to maintain the confidentiality of health information that identifies you. This notice explains the privacy practices that we maintain concerning your PHI.

 

The terms of this notice apply to all records containing your PHI that are created or retained by the Practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all your records that our Practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. You may request a copy of our most current notice at any time.

 

1. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

WE THE PEOPLE HEALTH AND WELLNESS CENTER

TANYA PARUS

• ​

(941) 265-1776

959 E. VENICE AVE. VENICE, FL.34285

 

1. WE MAY USE AND DISCLOSE YOUR PHI IN THE FOLLOWING WAYS:

 

The following categories describe the different ways in which we may use and disclose your PHI.Not every use or disclosure in a category will be listed:

 

1. Treatment. Our Practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Our staff may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as other healthcare providers, your spouse, your children or your parents.

 

1. Payment. Our Practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. We do not accept or bill insurance, so we do not disclose your information for the purpose of being reimbursed by insurance. However, we may use and disclose your PHI to obtain payment from those that may be responsible for such costs, such as family members.

 

1. Health Care Operations. The Practice may use and disclose your PHI to operate our day-to-day business. As examples of the ways in which we may use and disclose your information for our operations, our Practice may use your PHI to evaluate the quality of care you received from us, bookkeeping and accounting services, to develop protocols and clinical guidelines, to develop training programs and to aid in credentialing, medical review, legal services and insurance.

 

1. Appointment Reminders. The Practice may use and disclose your PHI to contact you and remind you of an appointment.

 

1. Release of Information to Family/Friends. The Practice may release your PHI when necessary, to a friend or family member that is involved in your care. For example, a parent or guardian may ask that a babysitter take their child to the Practice for treatment of a cold. In this example, the babysitter may have access to this child’s medical information.

 

1. Disclosures Required by Law. The Practice will use and disclose your PHI when we are required to do so by federal, state or local law and regulation.

 

1. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES:

 

The following categories describe unique scenarios in which we may use or disclose your PHI:

 

When required by law to collect information for the purpose of:

 

1. Health Oversight Activities. The Practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

 

1. Lawsuits and Similar Proceedings. The Practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process, by another party involved in the dispute, but only if we have tried to inform you of the request or to obtain an order protecting the information the party has requested.

 

1. Law Enforcement. We may release your PHI if required to do so by a law enforcement official:

• Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement

• Concerning a death we believe has resulted from criminal conduct

• Regarding criminal conduct at our offices

• In response to a warrant, summons, court order, subpoena or similar legal process

• To identify/locate a suspect, material witness, fugitive or missing person

• In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)

 

1. Deceased Patients. The Practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we may also release information for funeral directors to perform their jobs.

 

1. Organ and Tissue Donation. The Practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.

 

1. Serious Threats to Health or Safety. The Practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or health and safety of another individual or the public. Under these circumstances, we will only make disclosers to a person or organization able to help prevent the threat.

 

1. Military. The Practice may disclose your PHI if you are member of the U.S. or foreign military forces (including veterans) and if required by appropriate authorities.

 

1. Workers’ Compensation. The Practice may release your PHI if required for workers’ compensation and similar programs.

 

1. YOUR RIGHTS REGARDING YOUR PHI:

 

The health and billing records we maintain are the physical property of We The People Health and Wellness Center, LLC. The information in it, however, belongs to you. You have a right to:

           

1. Confidential Communications. You have the right to request that our Practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to the Privacy Offer, specifying your requested method of contact, or the location where you wish to be contacted. Our Practice will accommodate reasonable requests. You do not need to give a reason for your request.

 

1. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our discloser of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to the Privacy Officer. Your request must describe in a clear and concise fashion:

 

1. Information you wish restricted

2. Whether you are requesting to limit our Practice’s use, disclosure or both, and

3. To whom you want the limits to apply.

 

1. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to the Privacy Officer in order to inspect and/or obtain a copy of your PHI. Our Practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our Practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

 

1. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our Practice. To request an amendment, your request must be made in writing and submitted to the Privacy Officer. You must provide use with a reason that supports your request for amendment. Our Practice will deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the Practice; (c) not part of the Phi which you would be permitted to inspect and copy; or (d) not created by our Practice, unless the individual or entity that created is not available to amend the information.

 

1. Paper Copy of this Notice. You may receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact the Privacy Officer.

 

1. Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our Practice. To file a complaint with our Practice, contact our Privacy Officer at the address provided above. All complaints must be submitted in writing, and you will not be penalized for filing a complaint.

 

1. Right to Provide an Authorization for Other Uses and Disclosures. Our Practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. You have the right, at any time, to revoke your authorization to disclose your PHI. Simply send a written notice of revocation to the Privacy Officer at the address provided above. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note we are required to retain records of your care.

 

Again, if you have any question regarding this notice or our health information privacy policies, please contact the Privacy Officer listed above.

 

Acknowledgement

 

I hereby acknowledge that I have received and read this Notice of Privacy Practices by We The People Health And Wellness Center, LLC. I understand that I may request additional copies of this notice at any time.

 

 

Patient Name                                      _____________________________________________

 

Patient (or Guardian) Signature          _____________________________________________

 

Date:                                                   _____________________________________________

Thank you for choosing We The People Health and Wellness Center!

We The People Health and Wellness Center