Direct Primary Care Agreement – Individual
Exemplar Care DPC, PLC
This Direct Primary Care Agreement – Individual (“Agreement”) is made as of the date last signed below by and among Exemplar Care DPC, PLC, an Iowa professional limited liability company, together with its affiliates (“Exemplar Care”) and the individual listed below as patient (“Direct Patient”).
WHEREAS, Exemplar Care provides direct primary care and urgent care medical services in the State of Iowa by and through Iowa-licensed healthcare providers;
WHEREAS, in exchange for a Direct Service Charge paid by Employee Group, Exemplar Care agrees to provide Direct Patient with the Services described in this Agreement in accordance with the terms and conditions set forth in this Agreement; and,
WHEREAS, Exemplar Care shall not refuse to accept any new Direct Patient or discontinue care of an existing Direct Patient based solely on the new Direct Patient’s or the existing Direct Patient’s health status.
NOW, THEREFORE, in consideration of the foregoing recitals and the mutual promises and covenants contained herein, the parties agree as follows:
A. “Direct Patient” means “You,” “Your” or “You and Your family” as party to the Agreement.
B. “Direct Primary Care Agreement” is the Agreement between a Direct Provider and the Direct Patient, in which the Direct Provider agrees to provide the designated Primary Care Health Services for a specified period of time to the Direct Patient, for a Direct Service Charge.
C. “Direct Provider” is a term defined by defined by Iowa Code 135N.1(1)(f), and in this Agreement refers to Exemplar Care.
D. “Direct Service Charge” means a charge for Primary Care Health Services provided by a Direct Provider to a Direct Patient covered by a Direct Primary Care Agreement.
E. “Exemplar Care” is a Direct Provider and is licensed (or employs/contracts with providers that are licensed) to perform the specified primary healthcare services consistent with Iowa laws.
F. “Primary Care Health Services” means general health care services of the type provided at the time a patient seeks preventative care or first seeks health care services for a specific health concern. The Agreement includes coverage for the following Primary Care Health Services:
- Care which promotes and maintains mental and physical health and wellness;
- Care which prevents disease;
- Screening, diagnosing, and treatment of acute or chronic conditions caused by disease, injury, or illness;
- Patient counseling and education;
- Provision of a broad spectrum of preventive and curative health care over a period of time; and
- Coordination of care.
2. Scope of Services and Direct Service Charge.
Exemplar Care is a part of an affiliated group of Exemplar Care-branded businesses and has contracted with those affiliates to include certain Primary Care Health Services and non-medical personalized services within the Scope of Services as set forth on Appendix A (collectively “Services”). In exchange for receipt of the Services described in this Agreement, Direct Patient agrees to pay Exemplar Care a Direct Service Charge.
3. Additional Costs for Services Not Included in Direct Service Charge.
Direct Patient may need care not included in this Agreement’s definition of Services, such as hospitalizations, emergency room visits, specialists, and certain laboratory tests. Care not included in the definition of Services is not included in/covered by the Direct Service Charge. Exemplar Care may provide care that is not included in the Scope of Services set forth in Appendix A and, as such, is not included by the Direct Service Charge. If Exemplar Care provides such non-covered care, this will be communicated to the Direct Patient.
4. Patient Submission of Claims to Insurance Company; Limited Waiver of Insurance.
Exemplar Care will not bill Direct Patient’s insurance company for Services provided under this Agreement. The Direct Patient may submit a request for reimbursement to her or his insurance company if permitted under her or his insurance policy. Exemplar Care makes no representations that any of the fees Direct Patient pays under this Agreement may be recoverable from your insurance company. Direct Patient, in entering this Agreement acknowledges and understands that this Agreement is not an insurance plan, is not a contract for health insurance, and is not a substitute for health insurance or other health plan coverage. It will not cover hospital services, or any services not directly provided by Exemplar Care. To the extent that Direct Patient receives covered Services under this Agreement that are also covered by their insurance, Direct Patient waives: (a) any right to make an insurance claim; and (b) any obligation of Exemplar Care and its affiliates to file an insurance claim, with respect to such services.
This Agreement will commence on the date it is last signed and will extend for an initial term of one year. Following the initial one-year term, the Agreement shall automatically renew for successive one-year terms unless either party provides written notice to the other party of its intention to not renew at least 30 days prior to the end of the initial term or any successive renewal term.
a. Termination by Exemplar Care. Exemplar Care shall have the right to terminate the Agreement upon 30 calendar days of advance written notice to Direct Patient. Upon exercise of its right to terminate, Exemplar Care must refund all unearned direct service charges to the Direct Patient within 30 calendar days from the date of the notice of termination. Exemplar Care may terminate the Agreement for any of the following reasons:
- Direct Patient fails to pay applicable fees owed pursuant to Appendix A of the Agreement;
- Direct Patient has performed an act that constitutes fraud;
- Direct Patient repeatedly fails to adhere to the recommended treatment plan, especially regarding the use of controlled substances;
- Direct Patient is abusive, or presents an emotional or physical danger to the staff or other patients;
- Exemplar Care discontinues its operation; and
- Exemplar Care may terminate a Direct Patient without cause as long as the termination is handled appropriately (without violating patient abandonment laws).
b. Termination by Direct Patient. Direct Patient may terminate the Direct Primary Care Agreement at any time by providing written notice to Exemplar Care. Direct Patient must pay all outstanding earned direct services charges to the direct provider within 30 calendar days from the date of the notice of termination.
No Medicare or Medicaid Patients. At this time, Medicare patients and individuals eligible for Medicare cannot be treated by Exemplar Care via this Agreement. Medicare cannot be billed for any services performed by Exemplar Care via this Agreement. Direct Patient acknowledges that he/she are neither a Medicare beneficiary nor Medicare eligible. Direct Patient agrees that if he/she will become eligible during the term of this Agreement, he/she will notify Exemplar Care within 60 days prior to becoming eligible and this Agreement will be terminated upon Medicare eligibility and transitioned to Exemplar Care’s Concierge Agreement if patient chooses. Any excess fees will be refunded to Direct Patient and Exemplar Care will make every effort to provide the Direct Patient with names and contacts for primary care alternatives if Concierge Agreement is not adopted.
In addition, Medicaid patients are not eligible to be treated by Exemplar Care via this Agreement, and Medicaid cannot be billed for any services performed by Exemplar Care or be responsible for the Direct Service Charge. Direct Patient acknowledges that he/she is not a Medicaid beneficiary. Direct Patient agrees that if he/she enroll in Medicaid during the term of this Agreement, he/she will notify Exemplar Care within 60 days prior to such enrollment and this Agreement will be terminated upon Medicaid eligibility. Any excess fees will be refunded to Direct Patient and Exemplar Care will make every effort to provide the Direct Patient with names and contacts for primary care alternatives.
7. Privacy and Communication.
Direct Patient acknowledges that communications with Exemplar Care using email, fax, video chat, instant messaging, and cell phone are not guaranteed to be secure or confidential methods of communication. Exemplar Care will make an effort to secure all communications via passwords and other protective means and these will be discussed in an annually updated Health Insurance Portability and Accountability Act (“HIPAA”) “Security Risk Assessment.” Exemplar Care will make an effort to promote the utilization of the most secure methods of communication, such as software platforms with data encryption, HIPAA familiarity, and execution of HIPAA Business Associate Agreements with business associates. This may mean that conversations over certain communication platforms are highlighted as preferable based on higher levels of data encryption, but many communication platforms, including email, may be made available to Direct Patient. If Direct Patient initiates a conversation in which Direct Patient discloses Protected Health Information (“PHI”) on one or more of these communication platforms, then Direct Patient has authorized Exemplar Care to communicate with Direct Patient regarding PHI in the same format. A copy of Exemplar Care’s notice of privacy practices is available on its website and in written form at the request of the Direct Patient.
Exemplar Care shall provide at least 60 calendar days of advanced, written notice to Direct Patient of any of the following changes to the Agreement:
- Any change in the scope of the primary care health services covered under the Agreement.
- Any change in Exemplar Care’s locations where Direct Patient may access primary care health services.
- Any change in the out-of-office services that are covered under the Agreement.
- Any change in the Direct Service Charge.
- Any change in the additional costs for primary care health services not covered by the Direct Service Charge.
- Any change in the renewal terms.
No other amendment of the Agreement shall be binding on either party unless it is in writing and signed by all parties.
This Agreement shall not be assigned, delegated, sold, or transferred by either party without the other party’s prior written consent.
10. Change of Law.
If there is a change of any relevant law, regulation, or rule, federal, state, or local which affects the terms of the Agreement, the parties agree to amend the Agreement to comply with the law.
11. Entire Agreement.
This Agreement contains the entire agreement between the parties and replaces any earlier understandings and agreements whether he/she are written or oral.
This Agreement shall be governed and constructed under the laws of the State of Iowa, and all disputes arising out of the Agreement shall be settled in the court of proper venue and jurisdiction in Polk County, Iowa.
Patient acknowledges and accepts the following:
This Agreement is not health insurance and is not a plan that provides health coverage for the purpose of any federal mandates. This Agreement only covers the Primary Care Health Services described in this Agreement. It is recommended that Direct Patient obtain health insurance to cover healthcare services not covered under this Agreement. Direct Patient is personally responsible for the payment of any additional healthcare expenses incurred beyond or in addition to the Services covered by this Agreement.
Scope of Services and Direct Service Charges
1. Direct Patient’s monthly fee is payable on a prorated basis when you sign the Agreement and is due on the first day or the fifteenth of each month. Whichever comes first after the signing of the Agreement. Discounts are available for prepayment of annual fees.
At the date of this agreement, membership fees are as follows:
Direct Service Charge for Monthly Plans *
- Primary Member: $89/month
- Spouse / Domestic Partner: $69/month
- Dependents: $29/month
- For dependents under 26 years of age
- Family: $216/month
- 2 adults and 2+ children / dependents
*No Enrollment Fee
2. Scope of Services: The Services provided by Direct Provider to Direct Patient under this Agreement at participating Exemplar Care locations are as follows:
3. Locations: Services are available at any Exemplar Care direct primary care locations described on our website, https://www.exemplar.care/
* Exemplar Care has contracts with affiliated Exemplar Care entities, including Exemplar Care, PLC, to provide certain urgent care services within the Scope of Services. Neither Direct Patient nor their insurance will be charged for urgent care services provided by Exemplar Care, PLC, and Direct Patient hereby waives any insurance with respect to such urgent care services to the extent covered by this Agreement