COVID Services
COVID-19 SERVICES PATIENT AGREEMENT
This COVID-19 Patient Agreement (“Agreement”) specifies the terms and conditions under which, you, the undersigned patient (“Patient”) may voluntarily elect to participate in the healthcare offerings offered by PanchalMED PC, a New Jersey professional corporation (“Practice”), doing business as Paging Dr. Neil.
Background
The Practice, located in New Jersey, provides ongoing health care services to its patients in a direct primary care practice model (DPC). In exchange for certain periodic fees the Practice agrees to provide the Patient with certain Services under the terms and conditions contained in this Agreement.
Definitions
Services. In this Agreement, “Services” means the collection of medical and non-medical services provided to the Patient by the Practice under this Agreement, and which are described in Schedule A, which is attached and incorporated into this Agreement.
Practice’s one-time routine regardless of medical condition or necessity diagnostic exam with a supportive health data communication plan. The routine regardless of medical condition or necessity diagnostic exam and Health Data Communication Plan are collectively referred to as the Practice’s private fee “COVID-19 Program”, also the “Services.”
Services may be delivered at Patient’s residence, the Practice’s office, or a mutually agreed upon location, or as a telehealth visit coupled with a COVID-19 Program-supportive health data communication plan (“Health Data Communication Plan”).
Patient. In this Agreement, “Patient” “Member” “You” or “Yours” means the person/s for whom the Physician shall provide care; who has signed this Agreement.
SERVICES & BENEFITS
Services are made available by Practice to Patient in exchange for Patient paying private service subscription fees directly to Practice as outlined in Schedule A (“Services Fees”). Services exceed or are beyond those covered or reimbursed by Patient’s Medicare, Medicaid or any applicable private health insurance plan (collectively “Plan”).
For making the Services available to Patient, the Patient voluntarily pays Practice Services Fees. Services Fees compensate Practice for making the Services available, payable as specified in Schedule A. Services Fees may increase from time to time with the voluntary consent in advance by Patient but will apply to renewal terms. In the event Services Fees increase, Patient will receive notification in writing and the option of consenting to such an increase in advance.
Services Fees cover only the availability of Services. If Practice provides services other than the Services listed in Schedule A, Patient and Practice may mutually agree upon any additional charges, if any, to the extent the Patient’s Plan does not cover those services. Patient acknowledges that either Patient or Patient’s Plan will be responsible for any applicable additional charges for services outside those described in Schedule A. Any charges to Patient for any services outside of Plan coverage and not reflected in Schedule A will be at Practice’s usual, reasonable and customary rates and consented to in advance by Patient before any such charge is incurred by Patient. Any applicable co-payments or deductibles related to Plan-covered services delivered by Practice, to the extent Practice is in-network with the applicable Plan, will be collected by Practice from Patient.
The Parties agree that the required method of payment shall be electronic payment through a debit or credit card, or automatic bank draft. No personal or bank checks will be honored at any time.
The Patient is responsible for all costs/fees associated with procedures, medical imaging (radiology), laboratory testing, specimen analysis, supplies, medications including vaccinations, and any other service personally or not personally provided by the Practice staff and/or not listed in Schedule A. The patient is free to use their health insurance for third party vendor services if applicable and accepted by the third party vendors.
Patient shall be advised in advance of treatment of any additional fees or costs and may choose to obtain such optional services elsewhere. But if Patient chooses to receive such services from the Practice, payment of additional fees shall be due at the time of service and billed at the same time. Please refer to Schedule A for further cost structure.
Vaccines. If you elect to receive vaccinations through us, we require only verbal consent to schedule you for vaccinations. Given the volatile nature of vaccines, once these vaccines have been taken out of inventory and refrigeration, and are in route to you, you will be charged, regardless if you receive them or not. We ensure to have stable temperatures while in route but cannot guarantee their viability on return back into our refrigeration center, therefore we make them non-refundable at the onset of being taken out of inventory and refrigeration.
Note: The Services are designed to constitute eligible “medical expenses” under the Internal Revenue Code and thus are intended to be eligible for HSA, FSA and HRA funding, but no guarantee regarding eligibility is provided as each patient’s tax reporting and accounting status may vary. Please check with your tax professional or tax preparer for guidance to confirm HSA eligibility, and submit Services Fees to FSA and HRA administrators for potential FSA or HRA funding of Services Fees.
ELECTRONIC PRACTICE COMMUNICATIONS
The Practice endeavors to provide Patients with the convenience of a wide variety of electronic communication options. And although We are careful to comply with patient confidentiality requirements, and make every attempt to protect Your privacy, communications by email, facsimile, video chat, cell phone, texting, and other electronic means, can never be absolutely guaranteed to be secure or confidential methods of communications. You understand and acknowledge the above and You agree that by initiating the clause, and participating in the above means of communication, you expressly waive any guarantee of absolute confidentiality with respect to their use. You further understand that participation in the above means of communication is not a condition of membership in this Practice, that you are not required to sign this clause, and that you a have the option to decline any particular means of communication.
Email and Text Usage. By providing an e-mail address, the Patient authorizes the Practice and its staff to communicate with him/her by e-mail regarding the Patient’s “protected health information” (PHI).1 By providing cell phone number, and clicking next to the “YES” on the corresponding consent question, patient consents to text message communication containing PHI through the number provided. Patient further acknowledges that:
a. Email and text message are not necessarily secure methods of sending or receiving PHI, and there is always a possibility that a third party may gain access;
b. Although the Practice and its staff shall make all reasonable efforts to keep email and text communications confidential and secure, We cannot assure or guarantee the absolute confidentiality of these communications;
c. You also understand and agree that email and text messaging are not appropriate means of communication in an emergency, for dealing with time-sensitive issues, or for disclosing sensitive information. In an emergency, or a situation in which could reasonably be expected to develop into an emergency, You understand and agree to call 911 or go to the nearest emergency room, and follow the directions of emergency personnel.
d. You agree that email and text messaging are not appropriate means of communication in situations requiring a quick response. You further agree that if you use these methods, and do not receive a timely response you will contact the Physician or other staff by telephone.
Please refer to the separate Electronic Communications Agreement for further applicable details in this regard, which are integrated herein by this reference.
APPOINTMENTS AND SCHEDULING
Services and other related appointments with Practice are scheduled through electronic communication with the Practice’s Health Data Communication Plan. Services are designed to be delivered at the Patient’s home/workplace, Practice’s office, or alternatively via virtual care delivery. If Patient has an urgent concern related to routine diagnostic exam health questions or concerns, Patient shall contact the Practice, but in any emergency, Patient should call 9-1-1 and/or utilize emergency medical services available outside Practice.
Technical Failure. Neither the Practice, nor its staff shall be liable for any loss, injury, or expense arising from a delay in responding to Patient when that delay is caused by technical failure. Examples of technical failures:
i. failures caused by an internet or cell phone service provider;
ii. power outages;
iii. failure of electronic messaging software, or e-mail provider;
iv. failure of the Practice’s computers or computer network, or faulty telephone or cable data transmission;
v. any interception of e-mail communications by a third party which is unauthorized by the Practice; or
vi. Patient’s failure to comply with the guidelinesfor use of e-mail or text messaging, as described in this Agreement.
Physician Absence. From time to time, due to vacations, illness, personal emergency, attendance at continuing medical education sessions, other professional healthcare work requirements, or due to technical defects with either Patient’s or Practice’s electronic communication equipment, the Physician may be temporarily unavailable. When times of absences are known in advance, the Practice shall give notice to Patients so that they can schedule non-urgent care accordingly. During unexpected absences, Patients with scheduled appointments shall be rescheduled at the Patient’s convenience. In the case of an acute illness requiring immediate attention, Patient should proceed to an urgent care or other suitable facility for care. Charges from Urgent Care and any other outside provider are not included under this agreement and are the Patient’s responsibility.
MEDICARE
If Patient is or becomes Medicare eligible, Patient acknowledges that Practice is a participating Medicare provider and pursuant to applicable federal regulations Practice will submit reimbursement claims to Medicare for all Medicare-covered services provided to Patient by Practice. In no event may Patient submit to Medicare or Medicaid any private fee paid for Services, as Services are NOT covered or reimbursed by Medicare or Medicaid. Patient acknowledges and understands that Medicare will not pay for the Services referenced in Schedule A. Patient will enjoy communications and visits from Practice’s healthcare professionals that are neither hurried nor restricted by Plan coverage/reimbursement requirements.
DISPUTE RESOLUTION
Each Party agrees not to make any inaccurate, or untrue and disparaging statements, oral, written, or electronic, about the other. We strive to deliver only the best of personalized patient care to every Member, but occasionally misunderstandings arise. We welcome sincere and open dialogue with our Members, especially if we fail to meet expectations and We are committed to resolving all Patient concerns.
Therefore, in the event that a Patient is dissatisfied with or has concerns about any staff member, service, treatment, or experience arising from their membership in this Practice, the Member and the Practice agree to refrain from making, posting or causing to be posted on the internet or any social media, any untrue, unconfirmed, inaccurate, disparaging comments about the other. Rather, the Parties agree to engage in the following process:
a. Member shall first discuss any complaints concerns or issues with their respective Physician;
b. Their respective Physician shall respond to each of Member's issues and complaints;
c. If, after such response, Member remains dissatisfied, the Patient and Dr. Neil Panchal DO, President of PanchalMED P.C shall enter into discussion and attempt to reach a mutually acceptable solution.
d. If no resolution is found, a mutually accepted third party will be invited to arbitrate on behalf of both parties, and both parties accept the decision of arbitrator as being in good faith and final.
RELEASE OF LIABILITY
To the fullest extent permitted by law, I hereby release, discharge and hold harmless, Practice without limitation, from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 infection, monitoring & treatment plan, RT-PCR Test, Antibody Test or the disclosure of my test results.
COMPLIANCE WITH LAW
Practice agrees to make Services available for Services Fees with the intent to comply with all applicable laws. This Agreement shall be governed by and construed in accordance with the laws of the state in which Practice is located, without application of choice-of-law principles. If there is a change of any law, regulation or rule, federal, state or local, which affects the Agreement or the activities of either Party under the Agreement, or any change in judicial or administrative interpretation of any such law, regulation or rule, this Agreement shall be deemed modified so as to remain in compliance with such laws.
PRACTICE IS NOT AN INSURER
PanchalMED PC, is not an insurance company, and this Agreement not an insurance policy. Practice is not promising or delivering unlimited care or services for the Services Fees. Your participation in PanchalMED PC, and your subscription to any of its documents should not be considered to be a health insurance policy. Practice presumes that Patient is either eligible for Medicare or otherwise has a private or public Plan that provides health care coverage for essential healthcare services not covered by Services Fees. This Agreement does not include hospital services, or any services not personally provided by the Practice or its staff. You acknowledge that We have advised You to obtain or continue in full force, health insurance that will cover You for healthcare services not personally delivered by the Practice, including but not limited to specialist care and for hospitalizations and catastrophic medical events.
No Submission of Claims to Third Parties. Neither the Practice, nor its Staff, participates in any health insurance or HMO plans. Regardless of your membership in the Practice, You are always responsible for paying any additional health care expenses you may incur. If you have health insurance, it may include, at no additional charge, some of the preventive services which are also included in this Agreement. We may not bill your insurance for services provided to you under this Agreement. Therefore, we will not bill any insurance plan or prepare invoices for Patient’s to submit for reimbursement. Furthermore, as a DPC practice, We may not submit a claim for payment to any third party payor (such as insurance plans), for any services We provide to You. Neither can we provide you with a receipt or invoice reflecting charges for individual services because we are not a fee for service model. It is Your responsibility to ascertain whether any fees paid under this Agreement are reimbursable through an HSA, FSA or other spending account.
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge and agree that I have had the right to review a copy of PanchalMED PC (the "Practice") Notice of Privacy Practices prior to signing this consent, which provides me with a more complete description of potential uses and disclosures of my protected health information (PHI). I am aware that the Practice reserves the right to revise its Notice of Privacy Practices at any time. I am also aware that an updated copy of the Practice's Notice of Privacy Practices is available on the Practice's website.
CONSENT TO USE AND DISCLOSURE
I hereby consent to the Practice using and disclosing my PHI to carry out treatment, payment, and healthcare operations (TPO), including sharing my PHI with my primary care physician, outside providers who are involved in my care, organized health care arrangements ("OHCA") with which the Practice participates, that are involved in my medical treatment. I also hereby consent to the Practice disclosing my immunization history to health oversight agencies/registries for syndromic surveillance. I am aware that the Practice disclaims any liability or harm resulting from my incorrect or incomplete provision of my primary care physician's contact information.
CONSENT TO TREATMENT
Practice has informed me about the purpose of the COVID-19 examinations and tests, procedures to be performed, potential risks, and associated costs. Practice also provided me with an opportunity to ask questions before proceeding with COVID-19 examinations and tests, and I understand that if I do not wish to continue with the Consultations, sample collection, testing, or analysis of my sample, I may decline to receive continued services. By signing below, I have read the contents of this form in its entirety and voluntarily consent to undergo the COVID-19 Services with Practice.
Thereby request and consent to diagnostic, therapeutic procedures and medical treatment by the Practice as determined necessary in the professional medical judgment of my treating provider, including but not limited to electrocardiograms, X-rays, blood tests, and administration of medications and vaccinations. I am aware that the practice of medicine and related procedures is not an exact science and I acknowledge that no guarantees as to the outcome of any procedures, treatments or examinations have been made to me. Further, I consent to the Practice taking photographs, x-rays, or other images of me during the course of my care, which may be used for purposes of documenting my medical status, for my medical benefit and for purposes of medical education and teaching. I understand that it is my responsibility to notify the Practice if I am or may be currently pregnant and that x-rays may injure the fetus.
CONSENT TO CONTACT
For all items pertaining to TPO, including items pertaining to my clinical care, and my payment for services, such as appointment reminders, insurance items, laboratory results, and patient statements, I hereby consent to the Practice, or its designee: (1) calling my home phone, cell phone, business phone or other designated location, through the use of an automated dialing system, or prerecorded voice message (including by way of ringless call); (2) text messaging my home phone, cell phone, business phone, or other designated location (through an automated texting system or otherwise); (3) emailing me; and (4) mailing materials to my home or other designated location. I acknowledge that the foregoing consent applies to today's date of service, as well as to my previous dates of service with the Practice (if any). I acknowledge that the Practice cannot and does not guarantee the privacy, security, or confidentiality of an e-mail message or text message sent or received. I understand that I have the right to request that the Practice restrict how it uses or discloses my PHI to carry out TPO. However, the Practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form. I am consenting to the Practice's use and disclosure of my PHI as specified in the Notice of Privacy Practices, Electronic Communications Agreement and this Patient Consent for use and disclosure of PHI. I understand that I may revoke my consent in writing, except to the extent that the Practice has already made disclosures in reliance upon my prior consent.
SCHEDULE “A”
Services & Services Fees
The routine diagnostic exam delivered at Patient’s residence/workplace, the Practice’s office, a mutually designated location, or as a telehealth visit collectively constitute the “Consultation.” The Consultation is supported by the Health Data Communication Plan defined below. The Consultation and Health Data Communication Plan collectively constitute the private fee “Services.” Patient’s Services Fees are paid in exchange for Practice making Services available to Patient on a one-time basis.
1. Consultation
COVID-19 Care: a two-week remote telehealth monitoring program with access to a personalized symptom tracker, evidence-based guidance on SARS-CoV-2 virus testing, as needed symptom-based medication suggestions & appropriate prescriptions, evaluation for Monoclonal Antibody Treatment
Monoclonal Antibody Coordination: If Patient voluntary requests coordination for Monoclonal Antibody Treatment, Practice will review evaluation, find a hospital institution that has the capability of administering such treatment, and submit order requisition for Patient
COVID-19 PCR Testing: conduct scheduling and collection at Patient’s preferred location (e.g Home or Worksite), PCR sample collection, and submission to laboratory for RT-PCR analysis
COVID-19 Antibody Testing: conduct scheduling and phlebotomy at Patient’s preferred location (e.g Home or Worksite), and submission to laboratory for analysis
optional Spike Protein Antibody Testing
Telemedicine Services provided in this Agreement are those Services that are consistent with Physician’s training and experience, and as deemed appropriate at the sole discretion of the Physician. The Patient is responsible for all costs associated with any medications including vaccinations, laboratory testing, durable medical equipment, and specimen analysis associated with these Services.
2. Health Data Communication Plan Service
Practice will provide Patient the availability of Services to Practice’s online health data storage and communication facilitation platform plan to support the routine diagnostic exam and related Patient education (“Health Data Communication Plan”). The Health Data Communication Plan will facilitate and empower Patient to interact with Practice via electronic communication regarding Practice’s Services received by Patient. The Health Data Communication Plan will facilitate Patient/Practice Services-related communication in efforts to also provide Patient with guidance, education and support regarding related Services for Patient, as well as providing a platform to facilitate ongoing electronic communication exchanges between Practice and Patient regarding the Services Practice provided to Patient. Practice’s Health Data Communication Plan will also keep Patient’s medical information electronically stored so that, upon request of Practice’s healthcare professional, information can be retrieved and furnished to Practice’s healthcare professional to further support the Services Services made available by Practice for Patient.
3. Services Fee:
As listed on website. Subject to change.
COVID-19 PCR Testing Terms & Informed Consent
1. COVID-19 RT-PCR Test Information: I understand that the type of test I am signing up for is a COVID-19 molecular reverse-transcriptase polymerase chain reaction test (“COVID-19 RT-PCR Test”) to detect the presence of viral RNA. I also understand that this COVID-19 RT-PCR Test has been Food and Drug Administration (FDA) cleared or approved by FDA under an Emergency Use Authorization (EUA).
2. Informed Consent: I am at least eighteen (18) years old. I voluntarily consent and authorize Paging Dr. Neil (“Practice”), and Practice’s partners, any of their respective officers, directors, employees, representatives, and agents, to conduct collection, testing, and analysis for the purposes of a diagnostic COVID-19 RT-PCR Test for myself and/or my child(ren) and/or my legal dependent(s) as applicable. I hereby give my consent and authorize Practice’s state-licensed healthcare providers to collect my sample using a nasopharyngeal swab, oral swab, or other recommended collection procedures, in conformity with CDC guidelines and protocols. I understand that there are risks to the collection procedures, such as nosebleed or nasal passage soreness, but are not limited to, severe bleeding, infection, accidental injury to a nearby body part, incomplete repair, even death. The testing process may be unpleasant and uncomfortable. I willingly consent and permit Practice’s clinical laboratory certified under the Clinical Laboratory Improvement Amendments of 1988 (“CLIA”) to process and analyze the samples solely for the detection of the COVID-19 virus and not for any other medical purpose.
3. COVID Risk: I understand that there are risks and benefits associated with undergoing a diagnostic COVID-19 RT-PCR Test for COVID-19. I understand that Practice cannot guarantee that I will not become infected with the Coronavirus/Covid-19 as part of my COVID-19 RT-PCR Test. I also understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the conduct of the COVID-19 RT-PCR Test .
4. Test Results: I acknowledge that Practice is not providing any form of medical treatment related to COVID-19, and that I am solely responsible for seeking appropriate medical attention based on the COVID-19 RT-PCR Test results. I understand that COVID-19 RT-PCR Test results are not 100% accurate and there may be a potential for false positive or false negative results. A positive COVID-19 RT-PCR Test result for SARS-CoV-2 generally confirms the diagnosis of COVID-19; however, results may remain positive long after you are no longer infectious due to prolonged detection of RNA. I understand that there are asymptomatic carriers of the COVID-19 virus, so I may exhibit no symptoms yet test positive for COVID-19. I acknowledge that a positive COVID-19 RT-PCR Test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others. A negative COVID-19 RT-PCR Test result may just mean that I was not infected at the time the COVID-19 RT-PCR Test was done. I understand that I could still become infected at a later point, so it is important to continue to practice prevention measures such as physical distancing and washing my hands frequently.
5. Testing Process : I understand that I am responsible to complete the forms and provide the needed documentation for Practice to perform the COVID-19 RT-PCR Test. I understand that while most COVID-19 RT-PCR Test results are available within 24-48 hours after the COVID-19 RT-PCR Test is conducted, in some cases it may take longer to receive the results due to inconclusive results and high demand for COVID testing.
COVID-19 Antibody Testing Terms & Informed Consent
1. COVID-19 Antibody Test Information: I understand that the type of test I am signing up for is a COVID-19 Serum Antibody IgG test (“Antibody Test”) to detect the presence of serum IgG. I also understand that this COVID-19 Antibody Test has been Food and Drug Administration (FDA) cleared or approved by FDA under an Emergency Use Authorization (EUA).
2. Informed Consent: I am at least eighteen (18) years old. I voluntarily consent and authorize Paging Dr. Neil (“Practice”), and Practice’s partners, any of their respective officers, directors, employees, representatives, and agents, to conduct collection, testing, and analysis for the purposes of a diagnostic COVID-19 Antibody Test for myself and/or my child(ren) and/or my legal dependent(s) as applicable. I hereby give my consent and authorize Practice’s state-licensed healthcare providers to collect my sample using phlebotomy (peripheral vein blood draw) or other recommended collection procedures, in conformity with CDC guidelines and protocols. I understand that there are risks to the collection procedures, such as bleeding, bruising, pain, soreness, but are not limited to, fainting, severe bleeding, infection, accidental injury to a nerve or artery, incomplete repair, blood clots, even death. The testing process may be unpleasant and uncomfortable. I willingly consent and permit Practice’s clinical laboratory certified under the Clinical Laboratory Improvement Amendments of 1988 (“CLIA”) to process and analyze the samples solely for the detection of the COVID-19 antibodies and not for any other medical purpose.
3. COVID Risk: I understand that there are risks and benefits associated with undergoing an Antibody Test. I understand that Practice cannot guarantee that I will not become infected with the Coronavirus/Covid-19 as part of my test. I also understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the conduct of the Antibody Test .
4. Test Results: I acknowledge that Practice is not providing any form of medical treatment related to COVID-19, and that I am solely responsible for seeking appropriate medical attention based on the Antibody Test results. I understand that the presence of IgG and/or IgM antibody to SARS-CoV-2 indicates that the patient has developed an immune response to the virus. Although the immune response may protect against reinfection, this has yet to be conclusively established. It is not known how long antibodies to the virus will protect someone, if at all. Cases of reinfection with COVID-19 have been reported but remain rare. A positive result indicates detection of SARS-CoV-2 IgG, which indicates an immune response to a COVID-19 spike vaccine or recent/prior infection with SARS-CoV-2. It usually takes at least 10 days after symptom onset for IgG to reach detectable levels. Although the relationship between IgG positivity and immunity to SARS-CoV-2 has not yet been established, detection of IgG may suggest an immune response to SARS-CoV-2 after resolution of infection or in response to vaccination. It is currently not known for how long IgG remains detectable after vaccination or exposure to SARS-CoV-2. A negative (non-reactive) result indicates that SARS-CoV-2 IgG is not present at a level that is detectable by the SARS-CoV-2 Serology (COVID-19) Antibody (IgG), Immunoassay. Negative results suggest that a person has not been infected with SARS-CoV-2 or has been very recently infected (antibodies have not yet been produced). Such a patient is at risk of infection, however, the rate of IgG development varies between individuals.
5. Testing Process
I understand that I am responsible to complete the forms and provide the needed documentation for Practice to perform the Antibody Test. I understand that while most Antibody Test results are available within 3-5 days after phlebotomy is conducted, in some cases it may take longer to receive the results due to inconclusive results and high demand for testing