This Primary Care Membership Agreement (the "Agreement") is entered into and effective as of by and between Community Clinics at Memorial Regional Health ("Community Clinics") and , residing at

Community Clinics goal is to promote and improve the health of our patients and ensure access to cost effective primary care services. In consideration of the Membership Fees described below, Community Clinics agrees to provide the following services:

1. Covered Individuals This agreement covers you and the following persons who are a part of your household (Dependents):

Name
Date of Birth
Relationship
Self

Additional information on you and your Dependents is included in Schedule 1 of this Agreement.

2. Direct Primary Care Services. Community Clinics will provide you and your Dependents with direct primary care services ("Services") as follows:

3. Membership Fees. Your membership allows you and your Dependents to receive the Services for a flat membership fee paid to Community Clinics. You agree to pay Membership Fees for the Services as follows:

Initial
All boxes must be initialed
Fee
Individual Fee:
$ per month
Couple Fee:
$ per month
Dependent Child Fee:
$ per month per child
Total Membership Fee:
$ per month

4. Eligibility. Under applicable law, the Program is not available to anyone who is participating in Medicaid, Medicare or Tricare. You certify that neither you nor any Dependents participate in Medicaid, Medicare or Tricare, have applied to participate in Medicaid, Medicare, or Tricare, or intend to seek to apply or participate in such programs during the term of this Agreement. If you or any of your Dependents ever become covered under Medicaid, Medicare or Tricare, you must inform Community Clinics immediately and you or your Dependents’ participation in the Program will be terminated immediately.

5. Payment. Membership Fees are billed monthly, and payment is due within thirty (30) days of the invoice date. Late payments will incur interest of 1.5% per month. This Agreement and the Services may be terminated upon written notice to you if monthly invoices are not paid in a timeline manner.

6. Use of Flexible Spending Accounts. With prior written approval of your benefit plan, a flexible spending account may be used to pay for Membership Fees. Please consult your flexible spending account vendor for more information and to determine eligibility.

7. Changes to Services and Fees. Upon written notice to you, the Services and Membership Fees may be modified. Unless you choose to terminate the Agreement with written notice to Community Clinics, modifications to the Services and Membership Fees will automatically apply to this Agreement going forward.

8. Changes to Health Insurance Coverage and Payments. THIS AGREEMENT IS NOT A SUBSTITUTE FOR HEALTH INSURANCE COVERAGE. THIS AGREEMENT IS NOT HEALTH INSURANCE AND DOES NOT MEET ANY INDIVIDUAL HEALTH BENEFIT PLAN MANDATE REQUIRED BY FEDERAL OR STATE LAW. WHILE PARTICIPATING IN THIS PROGRAM, YOU AND YOUR DEPENDENTS ARE NOT ENTITLED TO THE HEALTH INSURANCE PROTECTIONS FOR CONSUMERS PROVIDED UNDER TITLE 10 OF THE COLORADO REVISED STATUTES IN CONNECTION WITH THIS AGREEMENT.

9. Claims to Insurers. COMMUNITY CLINICS WILL NOT SUBMIT ANY CLAIM FOR PAYMENT TO A HEALTH INSURER OR TO ANYONE ELSE FOR THE SERVIEWS OFFERED UNDER THIS AGREEMENT, EVENT IF IT MAY BE COVERED UNDER YOUR HEALTH INSURANCE PLAN. SERVICES MAY BE A COVERED BENEFIT OR COVERED SERVICE UNDER YOU RHEALTH BENEFIT PLAN OR HEALTH INSURANCE AND SOME OF THE DIRECT PRIMARY CARE SERVICES MAY BE PROVIDED AT NO COST TO YOU PURSUANT TO THE TERMS OF SUCH A HEALTH BENEFIT PLAN OR INSURANCE PLAN. BY PARTICIPATING IN THE PROGRAM, YOU AND YOUR DEPENDENTS UNDERSTAND THAT YOU MAY BE GIVING UP YOUR RIGHT TO COVERAGE FOR BENEFITS UNDER YOUR HEALTH INSURANCE PLAN.

10. Non-Covered Services.

  1. Your membership fee covers only the Services provided for in this Agreement which are rendered at Community Clinic’s designated locations.
  2. You are responsible for paying for all costs which are not expressly covered by this Agreement, including the costs of healthcare providers, insurance co-pays, co-insurance and deductibles, costs for non-covered services, services rendered at non-designated locations and any other costs or expenses outside the scope of this Agreement.
  3. Services which are not covered by this Agreement include, but are not limited to: specialty physician services (including without limitation, the services of orthopedic specialists, oncologists, cardiologists, neurologists, surgeons, ENTs, ophthalmologists, endocrinologists, and obstetrics/gynecologists); hospitalization and in-patient surgeries, procedures and treatments; outpatient surgical procedures; emergency department treatment or visits; durable medical equipment; over the counter medications; prescription medications; infusion services; optometry services; dental services or surgery; ambulance or other medical transport costs; cosmetic procedures; long-term care services; hospice care services; home health services; or any healthcare services you receive from a provider other than Community Clinics or at any non-designated location.

11. Term and Termination. The term of this agreement will be for TWELVE (12) MONTHS and will automatically renew for successive TWELVE (12) MONTH terms, unless terminated by you or Community Clinics. You may terminate this agreement at any time, either with respect to any Dependent or with respect to the entire Agreement, by providing written notice to Community Clinics. Community Clinics may terminate this Agreement at any time, upon thirty (30) days written notice, with respect to any Dependent or with respect to the entire Agreement. In addition, Community Clinics may terminate this Agreement immediately in the event of non-payment of Membership Fees. In the event you terminate the Agreement, Community Clinics will refund any prepaid Membership Fees within sixty (60) days of termination.

12. Miscellaneous. This Agreement is the entire agreement between you and Community Clinics and supersedes any prior agreements. This Agreement may be modified by Community Clinics upon advanced written notice to you. Community Clinics may agree to modifications to this Agreement which you may request in a writing signed by the parties. The laws of the State of Colorado govern this agreement. You may not assign this Agreement. If any provision of this Agreement is determined to be invalid, void or unenforceable (in whole or in part), the remaining provisions of the Agreement shall remain in full force and effect.

13. HIPAA. A copy of the Community Clinics’ Notice of Privacy Practices has been delivered to you.

IN WITNESS THEREOF, the parties have executed this Agreement.

Signature
(Use your mouse to draw your signature.)

Date: