NeuCare Member Terms & Agreement
GENERAL & DEFINITIONS
I acknowledge and understand that the person listed above is voluntarily becoming a “Member” of NeuCare, LLC (also known as “NeuCare” or “NeuCare Family Medicine”) and that this agreement is non-transferable.
I understand that “membership” refers to all services, including but not limited to healthcare and administrative tasks, the Member may receive from NeuCare.
I recognize that W. Ryan Neuhofel, DO, MPH (“Dr. Neuhofel”) is the owner and primary physician of NeuCare.
I understand this agreement and all its terms shall apply to Dr. Neuhofel, all employees, healthcare providers (including other physicians, nurse practitioners, physician assistants) and representatives of NeuCare.
I understand that at times other physicians or physician-extenders may provide care to the Member in Dr. Neuhofel’s absence or unavailability and they will be subject to these same terms and agreement.
I understand these Terms & Agreement shall replace and make void any previous Member Terms & Agreement with NeuCare.
I understand that I am entitled to a copy of this document should I request one.
SCOPE OF PRACTICE & AVAILABILITY
I understand that Dr. Neuhofel and NeuCare provide a limited set of health care services in the specialty of Family Medicine and the Physician’s ability to provide care may be limited by training, experience, equipment, supplies, outside facilities (i.e. hospitals) and other unforeseen situations.
I understand that Dr. Neuhofel has the ultimate right to decide what services NeuCare provides and that NeuCare may add or discontinue the services it provides at anytime at the discretion of the Physician.
I acknowledge that I may require health care and related goods outside of NeuCare and that Dr. Neuhofel may recommend outside care or services for some health issues.
I recognize that Dr. Neuhofel may be unavailable by phone or in-person at times due to vacations, illness, technical malfunctions or other unforeseen situations.
I understand that should the Dr. Neuhofel become unavailable, NeuCare will attempt to arrange alternative coverage with another health care provider but this coverage cannot be guaranteed at all times.
I understand that being a member of NeuCare requires payment of an ongoing, recurring membership fee and that the Member (and/or a sponsoring employer) must continue to pay membership fees to receive services and health care from NeuCare and the Physician.
I acknowledge that if under an employer-sponsored plan, the employer and the employee are entirely responsible for managing any payroll deductions that may be related to NeuCare and this membership.
I understand that the Member will be provided a limited set of services at no charge, including basic communications with the Physician and NeuCare, unlimited nurse and doctor visits at the clinic during regular business hours, some lab and diagnostic testing (including, but not limited to rapid strep test, cholesterol panel, chemistry panel, CBC, basic Pap smear, hemoglobin A1c, EKG, urine dipstick analysis, urine pregnancy), coordination of care and referrals to other providers, annual flu shot and medical equipment lease (including, but not limited to crutches, splints and slings).
I understand that the services and goods included in the membership fee are at the full judgment and discretion of NeuCare and these services and goods may change without notice.
I understand that some NeuCare services, including but not limited to after-hours visits (not during regular business hours), house calls, some labs, procedures, and medications, may require payment of an additional fee.
I acknowledge that if the Member’s membership fees are 60 days past-due from the date of billing, the Member’s membership and services will be cancelled.
I acknowledge that NeuCare may change the amount their membership fee at anytime in the future, but will notify me in writing of any changes at least 90 days prior.
I understand an initial membership fee must be paid upon joining and that payment is non-refundable.
I acknowledge that if joining as an individual (not sponsored by an employer), a one-time registration fee is required upon joining NeuCare and this fee is non-refundable.
If joining as an individual (not sponsored by an employer), I understand that upon cancellation of this membership, I will be refunded any pre-paid membership fees remaining on the account calculated on a pro-rated basis from the date of cancellation. Any refund due will be issued within 30 days from the date of cancellation.
If joining on an employer sponsored plan, I understand that any and all membership fees paid by my employer, or payroll deductions related to this membership, are non-refundable.
SERVICES FEES & OUTSIDE CARE
I understand that some NeuCare services, including but not limited to after-hours visits (not during regular business hours), house calls, some labs, procedures, and medications, may require payment of an additional fee. These fees are subject to change without notice, but NeuCare will always disclose any charges prior to rendering service.
I understand that I am entirely responsible for any charges the Member may incur related to health care services received outside of NeuCare, including but not limited to other physicians, emergency rooms, hospitalization, diagnostic testing, specialty services and prescription medications.
I acknowledge that NeuCare will not reimburse me for any charges the member may incur for any outside care received or paid.
INSURANCE, HEALTH PLANS & MEDICARE
I acknowledge and understand that NeuCare is NOT a health insurance plan, nor a substitute for health insurance.
I acknowledge that the Physician and NeuCare encourages, but not requires, all members to have some type of health insurance plan to help pay for health care services incurred outside of NeuCare.
I acknowledge that NeuCare does NOT participate in, or accept payment from, any health insurance plans; including but not limited to Medicare, Medicare Advantage plans, Medicaid, KanCare, PPOs, HMOs or TriCare.
I understand that NeuCare cannot guarantee reimbursement for any NeuCare services and resultant charges from any third-party health plans, including insurance plans and savings accounts (health savings or flexible spending).
I acknowledge that if I elect to receive services (including but not limited to diagnostic tests, labs, other physicians, medications) outside of NeuCare using a health insurance plan, including services that are ordered by the Physician or NeuCare, I assume full responsibility for properly submitting appropriate insurance information and to pay for any associated costs.
I confirm that the Member is NOT currently enrolled in traditional Medicare (Parts A or B) plans.
I understand that individuals enrolled in traditional Medicare (Parts A or B) are NOT eligible to be NeuCare members.
I agree to notify NeuCare immediately if the Member becomes enrolled in traditional Medicare for any reason, including but not limited to age, disease or disability.
I acknowledge that this contract cannot be entered into by a Medicare beneficiary, or a legal representative during a time when the Medicare beneficiary, requires emergency care services or urgent care services.
I understand that if the member is Medicare-eligible (or become eligible), they must be enrolled and maintain coverage with a Medicare Advantage (Part C) Plan to be an eligible NeuCare member.
I acknowledge that NeuCare is not a contracted provider for any Medicare Advantage Plans and NeuCare services will not be covered by these plans.
I agree to never seek reimbursement for payments made to NeuCare from Medicare or Medicare Advantage health plans.
CANCELLATION, LACK OF PAYMENT, REFUNDS & RE-ENROLLMENT
I acknowledge that that the Physician and I have an absolute and unconditional right to cancel this Agreement and NeuCare membership at any time for any reason.
I understand if membership fees are unpaid 60 days after scheduled payment or billing date, this membership may be cancelled and the Member will no longer be a member of NeuCare.
I must provide NeuCare a written or verbal notice of cancellation and understand that membership fees will continue to be billed or auto-paid until NeuCare receives such notice.
In addition, I understand that NeuCare may terminate this Agreement and this membership at the sole discretion of the Physician by providing me with written notice of cancellation. However, NeuCare will NOT terminate membership with me on the basis of health status or medical conditions.
I understand that if this membership is cancelled by myself or NeuCare, I will still be responsible for any past-due balances owed - including membership fees or service fees.
I acknowledge if a member re-joins NeuCare after a cancellation (actively or by lack of payment), they may be required to pay an additional “Re-Enrollment” fee in addition to other standard charges.
COMMUNICATIONS, HIPAA & PRIVACY
I understand that under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) and it’s subsequent regulations I have certain rights to privacy regarding my “protected health information” (herein referred to as “PHI).
I have reviewed and understand NeuCare’s Notice of Privacy Practices and acknowledge it is available for review online at http://www.neucare.net/privacy or in paper form by request.
I acknowledge that the Physician and NeuCare will keep the Member’s “PHI” confidential and private and in conformity with HIPAA.
I understand that the Member’s “PHI” can and will be used by NeuCare to (1) conduct, plan and direct medical treatments and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly, and (2) conduct normal healthcare operations such as quality assessments and physician certifications.
I understand that any and all methods of correspondence may be used by the Physician and NeuCare to generate information for the member’s medical records.
I understand that NeuCare offers, but does not require, some forms of communication (including web-based unencrypted email, text message, picture messaging, social media platforms, voicemail, online video conferencing and fax services) in discussion of “PHI” that cannot reasonably be guaranteed to be fully secure.
I acknowledge that NeuCare will only use the contact information (phone numbers, email address, usernames, etc.) provided by me upon registration, “Authorization for Communications” form or in subsequent updates.
I acknowledge that NeuCare advises the Member against using employer owned or operated computers or email in communications with NeuCare and that NeuCare will not assume any responsibility or consequences created from use of employer-owned computers or email.
I acknowledge that NeuCare recommends members NOT communicate health information about sensitive health topics (such as sexually related activities, HIV/AIDS or substance abuse issues) through unsecured (internet-based or otherwise) means.
When using electronic methods (email, website, etc.) the Member should reasonably expect to hear a response within 24 hours during regular business hours. If the Member has not received a response, the Member should contact NeuCare by phone or another means of communication.
I agree not to hold NeuCare or the Physician liable or accountable for any loss, injury, damages, costs, or expenses which are sustained or the result of any technical failures with respect to email or electronic services including, but not limited to, (1) technical failures attributable to any internet service provider, (2) power outages, failure of any electronic messaging software, or failure to properly address e-mail messages, (3) failure of the Practice’s computers or computer network, or faulty telephone or cable data transmission, (4) any interception of e-mail communications by a third party; or (5) member’s failure to comply with the NeuCare’s guidelines regarding use of electronic communications set forth in this agreement.
I acknowledge that email and other forms of online communication are not an appropriate means to discuss any potentially urgent or emergency medical needs or other time-sensitive issues. I should call 911 or visit nearest emergency room should I reasonably suspect a medical emergency.
By signing below, I acknowledge that I have read, understand and agree to the above Terms and Agreement. I have had the opportunity to ask questions about these terms and they have been answered to my satisfaction.
Signature of Member (or member’s parent/guardian) Today’s Date
Parent/guardian’s Full Name - if member is minor (under Age 18)