Wise Patient Direct Terms and Conditions

Wise Patient Direct Terms and Conditions – Updated 01/02/2017

State regulation for the provision of Direct Patient-Provider Primary Health Care is established by permanent law RCW 48.150 (http://apps.leg.wa.gov/rcw/default.aspx?cite=48.150&full=true).

I acknowledge and understand that I am voluntarily becoming a Wise Patient Direct member, as offered by Wise Patient Internal Medicine, a Washington Professional Limited Liability Company (herein “Wise Patient”), and that this agreement is non-transferable. The effective date of my Wise Patient Direct membership is the date on which I sign this document or joint Wise Patient Direct online, whichever is earlier. I have reviewed the Wise Patient Direct Services Guide and I have had the opportunity to ask questions and receive answers regarding its content.

I acknowledge and understand that this agreement does not provide comprehensive health insurance coverage, nor is it a contract of insurance, and that it provides only the health care services specifically described in the Wise Patient Direct Services Guide. Wise Patient will not bill insurance carriers for any included services specifically described in the Wise Patient Direct Services Guide. I will not seek reimbursement from any insurance carrier for the included services specifically described in the Wise Patient Direct Services Guide. If I do seek reimbursement from any insurance carrier for the services specifically described in the Wise Patient Direct Services Guide, I will be in violation of RCW 48.150, and will be held responsible for any financial damages incurred by Wise Patient on the basis of that violation.

I acknowledge and understand that I am responsible for any charges incurred for health care services performed outside of Wise Patient including, but not limited to, emergency room visits, hospital care, specialist care, medical imaging, laboratory tests performed by third parties, physical therapy, psychotherapy, massage, acupuncture, and chiropractic care. Additionally, I acknowledge and understand that I am responsible for any charges incurred for health care services provided at Wise Patient but not specifically described as ‘included’ in the Wise Patient Direct Services Guide.  

I acknowledge and understand that this Wise Patient Direct contract is not for Medicare enrollees. By signing this form I am acknowledging that I am not a Medicare enrollee.

I acknowledge and agree to pay my monthly membership fee on or before its due date, which shall start exactly one month after the effective date of my Wise Patient Direct memership and continue monthly. This payment will cover the prior month’s membership fee. In the event that I am unable to pay my fee(s) on time, and given a one week grace period, I understand that I will be charged a $30 late fee and that my service agreement may be terminated.

I acknowledge and understand that I may terminate my Wise Patient Direct membership at any time and for any or for no reason by providing written notice to Wise Patient. Monthly fees will continue to accrue until written termination notice is received. My membership fee for the last month will be prorated to include only the days prior to when my termination notice was received.

I acknowledge and understand that Wise Patient may terminate my Wise Patient Direct membership by providing me written notice. My membership fee for the last month will be prorated to include only the days prior to when my termination notice was received. Wise Patient will not terminate this Patient Agreement solely on the basis of health status or protected status.

I acknowledge and understand that in the event that I terminate my Wise Patient Direct membership, I will not be allowed to reestablish my Wise Patient Direct membership prior to the passage of one complete calendar year from the termination date.  

I agree to first bring any complaints about services I receive as a Wise Patient Direct member to the attention of Wise Patient staff. Unresolved complaints may be brought to the attention of the Office of the Insurance Commissioner for the State of Washington by calling the Consumer Advocacy department at: (800) 562-6900 (TDD 360-586-6241) or by email at cad@oic.wa.gov.

Fee Schedule:

I acknowledge and understand the following Wise Patient Direct membership fee schedule:

$100 per month

I acknowledge that Direct Primary Care is not a substitute for health insurance and that Wise Patient has encouraged me to maintain a current health insurance policy along side my Wise Patient Direct membership.  

I acknowledge and understand that Wise Patient may add or discontinue services, or may increase my fee schedule at any time (but no more than once per year), and that I will be given, in writing, at least sixty (60) days notice of such fee schedule changes.

I have read and agree with all of the above.

 

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