Concierge Medicine Patient Agreement

CONCIERGE MEDICINE PATIENT MEMBERSHIP AGREEMENT

INTRODUCTION

This Patient Membership Agreement ("Agreement") is entered into as of [__/__/____] ("Effective Date") between:

[PRACTICE NAME], a [State] [Entity Type] ("Practice"), and

[PATIENT FULL NAME] with date of birth [__/__/____] ("Patient").

This Agreement describes the terms of Patient's membership in the Practice's concierge/retainer medicine program. By signing below, Patient agrees to the membership fee structure, scope of services, and responsibilities outlined herein.

1. CONCIERGE MEDICINE PROGRAM OVERVIEW

The Practice operates a concierge/retainer-based medicine model. This means:

• Patient pays an annual (or monthly) membership fee to the Practice.
• In return, Patient receives enhanced access to providers, preventive care coordination, and other agreed services.
• The membership fee covers services outside the scope of traditional insurance billing (see § 2).
• Insurance coverage (Medicare, commercial, Medicaid) remains available for covered medical services.
• This is not a substitute for health insurance.

2. MEMBERSHIP FEE STRUCTURE

2.1 Annual (or Monthly) Membership Fee

Membership Fee: $[__________] per [year / month]

• Payment is due [in full annually on the Effective Date / monthly on the [__]th of each month].
• Accepted payment methods: [_____________________________________________]
• Invoices will be sent to: [_____________________________________________]

2.2 What the Membership Fee Covers

The membership fee covers the following services and benefits:

• ☐ Unlimited office visits (routine and complex consultations)
• ☐ Extended appointment times ([__] minutes standard)
• ☐ Same-day or next-business-day appointment availability
• ☐ Phone and/or secure messaging consultation (non-emergency)
• ☐ Care coordination with specialists and hospitals
• ☐ Preventive health counseling and wellness planning
• ☐ Advance care planning and legal document review (limited)
• ☐ [Other covered services: _________________________________________________]

2.3 Services NOT Covered by Membership Fee

The following services and costs are excluded from the membership fee:

• Insurance-covered medical services: Laboratory work, imaging, procedures, prescriptions, surgeries, and other services for which health insurance (Medicare, Medicaid, commercial) provides coverage.
• Medications and supplies: Patient remains responsible for copays, coinsurance, and deductibles under applicable insurance plans.
• Out-of-network specialist referrals: Patient may be referred to specialists, hospitals, or facilities outside the Practice's network. Patient's insurance coverage applies; if the specialist is out-of-network, Patient is responsible for balance billing.
• Emergency services: Emergency room visits, ambulance transport, and emergency stabilization are covered by insurance, not the membership fee.
• Optional services: Cosmetic procedures, executive health screening packages beyond the standard scope, travel medicine services, or other elective add-ons (unless separately agreed in writing).

2.4 Per-Visit Fees (if applicable)

In addition to the membership fee, Patient may be charged separate fees for:

• [_____________________________________________] at $[__________] per visit
• [_____________________________________________] at $[__________] per visit
• [_____________________________________________] at $[__________] per visit

These per-visit fees will be disclosed in advance, and Patient must agree in writing before services are rendered.

3. PATIENT RESPONSIBILITIES & INSURANCE COORDINATION

3.1 Maintenance of Health Insurance

Patient acknowledges that membership in this program does NOT substitute for health insurance.

• Patient agrees to maintain active health insurance coverage (Medicare, Medicaid, or commercial plan) or to self-pay for covered services.
• Patient is responsible for all copays, coinsurance, deductibles, and out-of-pocket costs under their insurance plan.
• The Practice will submit claims to Patient's insurance for covered services. Patient agrees to provide current insurance information and to notify the Practice of any changes.

3.2 Medicare Patients – Opt-Out Status Disclosure

The Practice has elected to opt out of Medicare (pursuant to 42 U.S.C. § 1395a(b)).

If Patient is a Medicare beneficiary, Patient must acknowledge:

• ☐ Patient is aware that the Practice is not accepting Medicare payment for any services.
• ☐ Patient understands that this membership agreement constitutes a private contract with the Practice.
• ☐ Patient agrees not to file a claim with Medicare for services provided under this Agreement (the Practice will also not submit claims).
• ☐ Patient agrees to be personally and fully responsible for payment of all services rendered, whether or not those services would normally be covered by Medicare.
• ☐ Patient understands that Medicare limits (fee schedules, benefit limits) do not apply and the Practice may charge any fees it deems appropriate.
• ☐ Patient acknowledges that Medigap (supplemental insurance) policies do not cover services under a private contract with an opted-out provider.
• ☐ Patient retains the right to use other physicians and healthcare providers who accept Medicare, for which Medicare will pay.

Medicare Opt-Out Affidavit: The Practice has filed an opt-out affidavit with the Centers for Medicare & Medicaid Services (CMS), effective for a 2-year period. This affidavit is renewed every two years unless the Practice provides notice to CMS of non-renewal.

3.2A (Alternative) Medicare Patients – Opted-In Status Disclosure

The Practice accepts Medicare patients and is opted in to Medicare (participates in Medicare billing).

If Patient is a Medicare beneficiary, Patient acknowledges:

• ☐ Patient is entitled to all Medicare benefits and protections.
• ☐ The Practice will bill Medicare for services covered by Medicare.
• ☐ Patient is responsible for applicable Medicare copays, coinsurance, and deductibles only.
• ☐ The membership fee covers services distinct from Medicare-covered services, such as extended appointment time, priority scheduling, wellness coordination, and care advocacy (not clinical care itself).
• ☐ Patient understands that Patient cannot be charged an additional fee for any service that Medicare covers (e.g., office visits for acute medical problems, lab work, imaging).
• ☐ Patient will not be treated differently or excluded from the Practice because of Medicare status.
• ☐ Medicare fee schedules and payment limits apply to Medicare-covered services.

3.3 Insurance Information & Claims Submission

Patient agrees to:

• Provide accurate and current insurance information (member ID, group number, effective date) at the time of this agreement and whenever coverage changes.
• Authorize the Practice to submit insurance claims for covered services.
• Notify the Practice immediately of any changes to insurance coverage, employment, or eligibility.
• Pay any copays, coinsurance, or deductibles required by the insurance plan at the time of service.

The Practice agrees to:

• Submit insurance claims timely and accurately.
• Provide Patient with copies of claims submitted and explanation-of-benefits (EOB) statements received.
• Respond to insurance company inquiries regarding clinical necessity and appropriateness of care.

4. NON-DISCRIMINATION

The Practice is committed to providing equal access to its concierge medicine program regardless of race, color, national origin, sex, gender identity, sexual orientation, age, disability, marital status, religion, veteran status, or any other characteristic protected by law.

• Patient will not be denied membership, charged different fees, or receive inferior services based on any protected characteristic.
• If Patient believes the Practice has discriminated against them, Patient may file a complaint with:
• The Office for Civil Rights (OCR), U.S. Department of Health & Human Services: www.hhs.gov/ocr
• Your state's medical board or attorney general
• The applicable state insurance commissioner

5. CONFIDENTIALITY, PRIVACY & HIPAA

5.1 Protected Health Information (PHI)

The Practice will maintain the privacy and security of Patient's Protected Health Information (PHI) in accordance with:

• HIPAA Privacy Rule (45 CFR §§ 164.500–164.534)
• HIPAA Security Rule (45 CFR §§ 164.308–164.318)
• State patient privacy laws
• Medical record confidentiality statutes

5.2 Patient Authorization for Use & Disclosure

Patient authorizes the Practice to use and disclose Patient's PHI for:

• Treatment: Providing medical care, coordinating with specialists, hospitals, and other providers.
• Payment: Submitting insurance claims, billing, and collections.
• Healthcare Operations: Practice management, quality assurance, staff training, and operational improvement.
• As required by law: Response to legal process, public health inquiries, or mandatory reporting.

Patient does not authorize disclosure of PHI for:

• ☐ Marketing or fundraising (unless separately authorized)
• ☐ Substance use disorder treatment records (requires separate 42 CFR Part 2 authorization)
• ☐ Psychotherapy notes (requires separate authorization)
• ☐ HIV status, genetic information, or other sensitive categories (unless separately authorized)

5.3 Business Associate Agreements (BAA)

The Practice uses third-party vendors (EHR software, billing companies, cloud storage, etc.) to deliver services. Patient acknowledges that these vendors may access PHI and have Business Associate Agreements (BAA) with the Practice requiring them to maintain privacy and security. A list of current Business Associates is available upon request.

5.4 Patient Rights

Patient has the right to:

• Request a copy of their medical records
• Request an amendment to their records
• Receive an accounting of disclosures of their PHI
• Request restrictions on use or disclosure (though the Practice is not required to agree)
• Request confidential communications
• File a privacy complaint with the Practice or with the U.S. Department of Health & Human Services, Office for Civil Rights

Contact the Practice's Privacy Officer at: [_____________________________________________]

6. CANCELLATION & REFUND POLICY

6.1 Patient-Initiated Termination

Patient may terminate this Agreement at any time by providing written notice to the Practice.

Refund Policy:

• Within 30 days of Effective Date (free trial period): Full refund, no questions asked.
• After 30 days: No refund of membership fees already paid. Membership benefits will terminate on the date specified in the termination notice (minimum [__] business days' notice required).
• Prorated termination: If Patient terminates mid-month or mid-year, the Practice will not prorate fees unless otherwise agreed in writing.

6.2 Practice-Initiated Termination

The Practice may terminate this Agreement for any of the following reasons:

• Non-payment of membership fees (after [__] days' written notice and opportunity to cure).
• Abusive, threatening, or harassing conduct toward Practice staff, providers, or other patients.
• Violation of this Agreement that is material and not cured within [__] days of written notice.
• Loss of the patient's insurance coverage if the Practice requires active insurance coordination (for opted-in practices).
• Clinical reasons, as determined by the patient's provider (e.g., inability to meet clinical needs; patient requesting services outside the scope of the Practice's expertise).

Termination Procedures:

• The Practice will provide at least [30] days' written notice of termination (except in cases of imminent harm or safety concerns).
• Upon termination, the Practice will transfer medical records to Patient's new provider or to Patient directly, in compliance with HIPAA and state law.
• Unused membership fees (if any) will be [refunded / forfeited], consistent with the policy above.

6.3 Emergency & Continuity of Care

Termination of this Agreement does not eliminate Patient's right to emergency or urgent care:

• If a medical emergency arises after termination, the Practice's providers will provide necessary care.
• The Practice will ensure continuity of care during any transition, including timely forwarding of medical records.

7. DISPUTE RESOLUTION & ARBITRATION

7.1 Good Faith Negotiation

Before pursuing any legal action, Patient and the Practice agree to attempt to resolve disputes through good faith negotiation. Either party may request a face-to-face or phone meeting with the Practice's medical director or administrator.

7.2 Arbitration of Disputes

Except as noted below, any dispute arising out of or related to this Agreement, including claims for breach of contract, medical malpractice, negligence, or any other cause of action, shall be resolved by binding arbitration before a neutral arbitrator.

Exceptions – Claims not subject to arbitration:

• Claims arising under federal antitrust law
• Claims for violation of the Americans with Disabilities Act (ADA)
• Claims for violation of Title VII of the Civil Rights Act
• Workers' compensation claims
• Unemployment insurance claims
• Any claim that cannot be subject to arbitration under applicable law

Arbitration Process:

• Arbitration shall be conducted under the rules of [JAMS / American Arbitration Association (AAA) / [________]] using a single neutral arbitrator.
• Arbitration shall take place in [County], [State], unless the parties agree otherwise.
• The arbitrator shall apply applicable substantive law and may award any relief that a court could award.
• Each party bears its own attorney's fees and costs, except that the arbitrator may award fees and costs as permitted by law (e.g., in cases of frivolous claims or defenses).
• The prevailing party may seek to enforce the arbitration award in any court of competent jurisdiction.
• Either party may opt out of this arbitration clause by mailing written notice to the other party within 30 days of the Effective Date.

7.3 California-Specific Arbitration Limits

If Patient resides in California:

• Patient retains the right to file a claim in California's administrative and judicial forums (e.g., California Medical Board, Department of Managed Care, state courts) without limitation.
• Arbitration may not be used to limit Patient's right to seek administrative remedies or public agency relief.
• If any portion of this arbitration clause is found unenforceable, the remainder shall remain in effect.

7.4 Governing Law

This Agreement shall be governed by and construed in accordance with the laws of [State], without regard to its conflict-of-laws principles.

8. INFORMED CONSENT & ACKNOWLEDGMENT

Patient acknowledges that:

• ☐ Patient has read and fully understands this Agreement.
• ☐ Patient has been given an opportunity to ask questions and to consult with an attorney before signing.
• ☐ Patient understands the scope of services included in the membership fee and the services excluded.
• ☐ Patient understands the membership fee structure and payment terms.
• ☐ Patient understands that this Agreement does not guarantee any specific clinical outcome and does not substitute for medical decision-making by Patient's healthcare provider.
• ☐ Patient understands that the Practice may refer Patient to specialists, hospitals, or emergency services outside the Practice, and Patient is responsible for arranging payment with those outside providers.
• ☐ Patient understands applicable Medicare (or insurance) rules, including opt-out status if applicable.
• ☐ Patient consents to the use and disclosure of PHI as described in § 5.
• ☐ Patient consents to binding arbitration of disputes (except where excepted by law).

9. MODIFICATION & ENTIRE AGREEMENT

9.1 Entire Agreement

This Agreement, together with any addenda or exhibits, constitutes the entire agreement between Patient and the Practice regarding concierge medicine services. It supersedes all prior negotiations, representations, and understandings.

9.2 Amendments

The Practice reserves the right to amend this Agreement, provided:

• The Practice provides Patient with at least [60] days' written notice of material changes.
• Material changes include modifications to the membership fee, scope of covered services, or termination provisions.
• Patient's continued use of the Practice's services after the notice period constitutes acceptance of the amended terms.
• Patient may terminate the Agreement without penalty if Patient does not accept material amendments.

10. STATE-SPECIFIC VARIATIONS

CALIFORNIA PRACTICES

CA requires:

• Arbitration agreements must be presented in a clear, neutral manner (not one-sided).
• Patient retains the right to seek administrative remedies (CA Medical Board, Department of Managed Care).
• Non-renewal of insurance must not be a basis for termination without sufficient notice.

CA Insurance Code § 1793.5 (Managed Care Disclosure):
If the Practice contracts with a Medi-Cal or Commercial managed care plan, additional disclosures of plan limits and out-of-pocket costs apply.

TEXAS PRACTICES

TX allows concierge medicine but requires:

• Clear disclosure of the membership fee and what it covers/excludes.
• Compliance with Texas Medical Board Rule § 165.1(a)(2)(B) (advertising restrictions).
• Confirmation that Patient is aware of the opt-in/opt-out status (if Medicare involved).

FLORIDA PRACTICES

FL allows concierge medicine but requires:

• Compliance with FL Statute § 627.409 (patient notice of cancellation).
• Clear documentation that the membership fee is not a premium subject to state insurance regulation (it is a professional services fee).
• Notice that the Practice may not abandon a patient with an acute condition without reasonable care for transition.

NEW YORK PRACTICES

NY requires:

• Compliance with NY Education Law § 6527 (patient consent to treatment).
• For opted-out Medicare practices: clear written disclosures that Medicare does not cover services.
• Notice of the right to file a complaint with the NY Department of Health or Department of Financial Services.

11. ADDITIONAL IMPORTANT NOTICES

11.1 No Guarantee of Outcomes

Patient acknowledges that no warranty or guarantee of clinical results is made. Medical care involves inherent risks and uncertainties. The Practice does not guarantee a specific diagnosis, treatment plan, or outcome.

11.2 Emergency & Urgent Care

If Patient experiences a medical emergency, Patient should call 911 or go to the nearest emergency room. The Practice is not responsible for emergency care rendered by hospitals, emergency departments, or emergency medical services.

11.3 Telehealth Services (if applicable)

If the Practice offers telehealth or remote consultations:

• Telehealth services are subject to state and federal regulations, including requirements that the patient and provider be in the same state (with limited exceptions).
• Patient must ensure a private, secure location for telehealth visits.
• The Practice is not liable for technology failures or interruptions.
• Patient consents to the use of telehealth platforms and any associated vendors.

11.4 Contact Information

Practice Contact:

• [PRACTICE NAME]
• [ADDRESS]
• [PHONE NUMBER]
• [EMAIL ADDRESS]
• [WEBSITE]

Billing Inquiries: [BILLING EMAIL / PHONE]

Privacy Officer: [PRIVACY OFFICER NAME / EMAIL]

Complaints: [COMPLAINTS PROCESS / EMAIL]

SIGNATURE SECTION

IN WITNESS WHEREOF, Patient and the Practice have executed this Agreement as of the date first written above.

PATIENT

Patient Name (Print): _________________________________________________________

Patient Signature: _________________________ Date: [__/__/____]

Patient Address: _________________________________________________________________

Patient Phone: _________________________ Email: _____________________________

Patient Date of Birth: [__/__/____]

Patient Health Insurance (if applicable):

• Insurance Company: _____________________________________________________________
• Member ID: _________________________ Group #: _______________________________
• Effective Date: [__/__/____]

PRACTICE

Practice Name (Print): _________________________________________________________

Authorized Representative (Print): ________________________________________________________

Title: _________________________________________________________________

Authorized Representative Signature: _________________________ Date: [__/__/____]

Practice Address: _________________________________________________________________

Practice License Number (Physician/NP): ___________________________________________

Medicare Opt-Out Status: ☐ Opted Out | ☐ Opted In | ☐ Not Applicable

ACKNOWLEDGMENT OF RECEIPT

Patient acknowledges receipt of:

• ☐ A copy of this signed Agreement
• ☐ Notice of privacy practices (Privacy Policy)
• ☐ [Addendum on insurance coordination]
• ☐ [Addendum on telehealth (if applicable)]
• ☐ [Addendum on opt-out affidavit (if applicable)]
• ☐ [Other: _______________________________________________________________________]

Patient Signature: _________________________ Date: [__/__/____]

SOURCES AND REFERENCES

• 42 U.S.C. § 1395a(b): Private contracts with Medicare beneficiaries; opt-out requirements
• 45 CFR §§ 164.500–164.534: HIPAA Privacy Rule
• 45 CFR §§ 164.308–318: HIPAA Security Rule
• Centers for Medicare & Medicaid Services (CMS): Medicare Opt-Out Affidavit Forms and Instructions (available at cms.gov)
• American Medical Association: Concierge Medicine Resources
• State Medical Boards: Check your state's specific rules on concierge/retainer medicine
• California – CA Medical Board, CA Insurance Commissioner; CA Insurance Code § 1793.5
• Texas – Texas Medical Board Rule § 165.1
• Florida – FL Statute § 627.409; FL Board of Medicine
• New York – NY Education Law § 6527; NY Department of Health; NY Department of Financial Services