Saint Vil Medical Care Services LLC/
dba F.A.S. URGENT CARE CENTER
All the information at this agreement stay the same but from now on we don't provide monthly F.A.S. telemed membership we do only yearly F.A.S. membership
Private Pay Agreement/Patient Service Agreement
Note: You need to make a choice about receiving these health care services. The purpose of this Agreement is to help you make an informed decision about whether or not you want to receive telemedicine/phone consultation services, knowing that you will have to pay for it yourself.
PRIVATE PAY AGREEMENT/PATIENT SERVICE AGREEMENT
This Patient Service Agreement is entered into between Saint Vil Medical care Services LLC and the undersigned patient (“Patient”) for membership in Saint Vil Medical Care Services LLC’s uninsured Florida patient and telemedicine access to the services defined herein (the “Agreement”).Saint Vil Medical Care Services LLC and Patient shall hereinafter be referred to as individually the “Party” and collectively as the “Parties.”
This Agreement is NOT A HEALTH INSURANCE POLICY and does not cover services or care given by any other facility. This Agreement includes only the specific services as outlined in this Agreement, and does not include any medications, lab work, imaging, major catastrophic medical care provided by emergency rooms, hospitals, urgent care centers, services rendered by specialists or specialty clinics, or other entities.
1.SAINT VIL MEDICAL CARE SERVICES LLC
A. Saint Vil Medical Care Services LLC is a professional medical services entity that provides telehealth services that enables its Members to access and consult with a licensed professional anytime, anywhere via Saint Vil Medical Care Services LLC’s proprietary system, methods and protocols. As a Member, Patient will have unlimited access to certain member services, including, but not limited to, an ________________Patient Portal (“Member Services”).
B. Professional Services. Patients will have from 0800 AM to 0800 PM every day access to professional medical services from Saint Vil Medical Care Services LLC,
licensed physicians or supervised physician assistants and/or nurse practitioners (“Professionals”) via telemedicine and other applications (“Professional Services”).
C. Patient acknowledges and understands that he or she will not receive any services from Saint Vil Medical Care Services LLC or its Professionals unless defined as a Member Service or Professional Service under this Agreement or Saint Vil Medical Care Services LLC policy. Patient acknowledges and understands that Sain Vil Medical Care Services LLC and its Professionals are engaged for limited purposes and are not his or her specialized practitioner.
D. Saint Vil Medical Care Services LLC and its Professionals may prescribe medicines or other treatments, procedures, services or products to Patient in connection with Patient’s treatment; however, to the extent that such prescriptions or other treatments, procedures, services or products are discussed by the Professionals, neither Saint Vil Medical Care Services LLC (to the extent applicable), nor the Professionals shall be deemed to be making claims, express or implied, as to the efficacy for any medical condition. Patients shall contact a specialist regarding any issues that may be identified or arise during receipt of Member Services and Professional Services pursuant to this Agreement.
E. Covered Member Services include: Headaches, Coughs, Colds, Flu, Sprains, Sinus and Ear infections, Sore Throat, Fever, Rashes, Diarrhea, Back Pain, Asthma, Bronchitis, Pneumonia, Kidney and Bladder infections. Diabetes, Arthritis, Acid Reflux, High Blood Pressure, High Cholesterol, Cardiovascular disease, Chronic Fatigue, Fibromyalgia, Asthma, COPD, Non-Narcotic Pain Management and Low Back Pain. If applicable, Well-child evaluations. Non-life threatening medical issues under Saint Vil Vil Medical Care Services LLC’s sole discretion.
F. Excluded services: All non-telemedicine issues including, but not limited to, chronic pain management, substance abuse withdrawal, major surgeries, procedures involving general or regional anesthesia, CT scans, MRI scans, Echocardiograms, Cardiac stress tests, Pre-natal and obstetrical care, Electroencephalograms, Medications, Injections of any type administered in-office, Any care given by a provider not listed as participating in this membership, Any care in the sole determination of the provider that is best handled in the emergency room of a hospital, Any procedure in the sole determination of the provider that falls outside of his or her area of training or expertise, or Care rendered by specialists or specialty clinics.
G. Patient acknowledges and understands that the scope and delivery of the Saint Vil Medical Care Services LLC Services set forth in this Section may be amended or modified at any time at the sole discretion of Saint Vil Medical Care Services LLC .
2. BILLING AND PAYMENT
A. Registration and Membership Fees. Each Patient shall be responsible for and agrees to pay a yearly $__________________ Registration Fee (“Registration Fee”) upon enrollment and $_____________ membership fee per calendar month (“Membership Fee”). The Membership Fee shall cover all costs and expenses owed by Patient for access to and receipt of Member Services as defined in Section 1.1 herein. If Patient elects to enroll his or her immediate family members, Patient’s family members shall have their own membership separate and apart from the Patient. Each covered family member shall be considered separately for any fees set forth herein for services received pursuant to this Agreement.
B. Patient understands and agrees that the initial Membership Fee shall be paid prior to enrollment by completing the payment forms available online (_____________________________). The Membership Fee will be a monthly recurring, automatically renewing fee scheduled to occur based on the date that Patient first enrolls as a Member.
C. Membership fees shall be paid monthly and Registration fees are paid yearly as charges to the Member’s credit card, debit card, or automatic bank draft. Billing Processing is through ____________. Subsequent charges to the Member’s card or bank account will occur every month on the same day of each month. Member shall update credit card, debit card, or banking information when necessary and in a timely manner, and will be responsible for any amounts owed to Saint Vil Medical Care Services LLC, regardless of whether the account or card is expired, canceled, or otherwise not accepted for payment. Member(s) agree to pay a $25 added charge for each time the Member(s) account declined payment of the monthly charge.
D. This Agreement authorizes Saint Vil Medical Care Services LLC, or their chosen processor, to keep credit card, debit card, or banking information on file, and to charge the Member’s applicable account for monthly fees without requiring Dr, Frantz Sainvil MD, to obtain written authorization for each new charge.
E. If the Membership Fee is not paid by the fifteenth (15th) day of each month, except if due to an error or failure by Saint Vil Medical Care Services LLC or its representatives, Patient may be subject to a late charge of $5.00 (USD) per member and interest thereafter at the rate of one and one-half percent (1.5%) per month on the outstanding balance, or the highest amount permitted by law, whichever is lower.
F. Patient understands that WITHOUT EXCEPTION, all Members included in this Agreement will not be scheduled for a patient appointment unless the membership fees have been paid up through or beyond the date of the desired
appointment. An inability to collect membership fees due to incorrect or outdated billing information will result in the termination of my Saint Vil Medical Care Services LLC membership.
G. Saint Vil Medical Care Services LLC may, but is not required to, offer discounted fees or similar incentives to Patient from time-to-time depending on financial hardship, without changing the Patient’s liability for the fees incurred hereunder, it being explicitly agreed that Saint Vil Medical Care Services LLC is under no obligation to extend such other discounted fees or incentives to Patient. Saint Vil Medical Care Services LLC has sole discretion as to who receives discounts, the amounts of discounts, when discounts are issued and all other issues related to the issuance of discounts.
H.The fee amounts in this Section may change annually or at any time pursuant to an amendment to this Agreement at the sole discretion of Saint Vil Medical Care Services LLC for any reason. Saint Vil Medical Care Services LLC shall provide online notice of such change at least thirty (30) days prior to the effective date of any rate increase, unless such rate increase is caused by a change in law or regulation, or a change in the cost of providing services, in which case, Saint Vil Medical Care Services LLC may give notice of an immediate rate change.
I. Patient understands that the fees in this Section do not include the costs of any prescription medicines or other treatment, procedure, service or product provided by separate independent entities or individuals that may be prescribed or recommended by Saint Vil Medical Care Services LLC and its Professionals in connection with the Patient’s treatment. Patient understands that he or she may receive one or more separate bills for such prescription medicines and other treatments, procedures, services or products and is wholly responsible for payment of such costs, and further understands, that the independent entities and individuals will have their own billing and collection practices.
3. INSURANCE DISCLAIMER
A. Patient represents and warrants that the Saint Vil Medical Care Services LLC Services to be provided pursuant to this Agreement are not covered under any public or private health insurance program. Notwithstanding the above, Patient understands and agrees to be wholly responsible for the payment of any and all costs due and that may become due pursuant to this Agreement, regardless of the existence of coverage for such items or services under any public or private health insurance program.
B. Patient understands and agrees not to submit a claim, bill to or seek reimbursement from any public health program (i.e. Medicare, Medicaid, Tricare, Veterans Affairs and Federal Benefits) or any private health insurance plan or worker’s compensation plan for any item or service received pursuant to this Agreement. Patient understands that he or she will not be able to appeal any
determinations that public health program, private health insurance plan, or worker’s compensation plan will not pay for any item or service received pursuant to this Agreement.
4. Patient Responsibilities
A. Patient understands that it is the Patient’s responsibility to gain access to a telephone, computer, email, the internet or video conferencing service to facilitate the provision of Saint Vil Medical Care Services LLC’s Services under this Agreement.
B. Patient understands that it is the Patient’s responsibility to provide Saint Vil Medical Care Services LLC and its Professionals with accurate and complete medical records, history and descriptions of the Patient or covered family member’s condition and physical well-being. Patient understands that, as with any service, to the extent that information provided is not accurate and complete, the services provided by Saint Vil Medical Care Services LLC and its Professionals may be materially affected and Patient assumes any risk, and takes full responsibility and waives any claims against Saint Vil Medical Care Services LLC and its Professionals for personal injury, death or damages as a result and agrees to the extent permitted by applicable law to defend, indemnify and hold harmless Saint Vil Medical Care Services LLC and its Professionals from and against any and all claims of any nature including all costs, expenses and attorneys’ fees, which in any manner result from inaccurate or incomplete information provided by Patient or its authorized representative.
5. Term and Termination
This Agreement shall automatically renew each month from the first day of the month after the Patient first enrolls as a Member. Patient may immediately terminate this Agreement without cause upon written (Customer Support,15415 N Florida Ave ,Tampa Florida 33613 ) or electronic (___________________) notice to Saint Vil Medical Care Services LLC. If Patient terminates this Agreement, he or she will not receive a pro-rata refund of the remainder of the month’s Membership. Patient will be allowed to access Member Services and Professional Services for the remainder of the month if applicable. If Patient terminates this Agreement within five (5) days prior to the next recurring, automatically renewing, monthly billing cycle, Patient will be responsible for the next month, during which such time Patient will have access to the Member Services and Professional Services, and this Agreement will terminate at the expiration of said next month. Termination of this Agreement shall not relieve Patient of responsibility for any obligation, whether of payment or performance, incurred prior to termination but remaining unsatisfied as of the date of termination. There shall be a $35 cancellation fee if Patient terminates this Agreement enrollment within ninety (90) days based on the date that Patient first enrolls as a Member.
A. Patient Consent. If Patient is unable to sign, consent for treatment is given by his or her duly authorized representative. For purposes of this agreement, the term “Patient” includes any representative(s) of Patient authorized to make decisions and sign this Agreement on the Patient’s behalf.
B. Notice of Privacy Practices. Patient acknowledges having access to and reviewed Saint Vil Medicare Services LLC’s Notice of Medical Information Privacy Practices made available on-line (_____________________), which provides information about how Saint Vil Medical Care Services LLC and its Professionals may use and disclose the Patient’s protected health information. The Notice of Medical Information Privacy Practices may be subject to change. If you have any questions about our Notice of Medical Information Privacy Practices, please contact a designated representative.
C. Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations
Patient understands that as part of his/her healthcare,Saint Vil Medical Care Services LLC originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. Patient understands that this information serves as:
• A basis for planning my care and treatment.
• A means of communication among the many health professionals who contribute to my care, and I authorize the disclosure of such medical information with my health care providers.
• A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.
If Member intends to restrict medical information that may be shared with or disclosed to other health care providers, Member will provide, in writing to Saint Vil Medical Care Services LLC, such request and the specific medical information that is to be restricted. Member fully understands accepts the terms of this consent.
C. Assignment. Patient shall not assign this Agreement, nor its right, title or interest herein assigned, transferred, conveyed, sublet or otherwise disposed of without the express written consent of Saint Vil Medical Care Services LLC and any attempts to assign this Agreement without written consent are null and void. Saint Vil Medical Cae Services LLC will not necessarily be the provider of services under this Agreement and Patient may be provided services under this Agreement by a contracted professional medical individual or entity. Patient agrees that Saint Vil
Medical Care Services LLC may delegate responsibilities related to the Saint Vil Medical Care Services LLC’s Services to one or more independent contractors.
D. Third Party Software. Saint Vil Medical Care Services LLC does not warrant any software created or licensed in connection with the Patient Portal (“Third Party Software”). Warranties with respect to Third Party Software are subject to such limits and conditions as are contained in the license agreements for the Third Party Software. Patient will be considered to have accepted the license agreements for the Third Party Software upon execution of this Agreement. Patient agrees that the Third Party Software is a documentation tool only, and that the Third Party Software is not intended to provide diagnoses, practice guidelines, advice or protocols for delivering medical care. Patient further agrees that it shall be solely responsible to ensure that the documentation of medical care is accurate. Under no circumstances Saint Vil Medical Care Services LLC shall have any responsibility or liability as a result of this Agreement in connection with the Third Party Software for decisions made or actions taken or not taken in rendering medical care or for information provided to Patient or insurance companies, government agencies, or other payers.
E. Carrier Lines. Patient acknowledges that in connection with the access and use of Saint Vil Medical Care Services LLC Services that such services will be provided over various facilities and communications lines, and information may be transmitted over local exchange and internet backbone carrier lines and through routers, switches, and other devices (collectively, “Carrier Lines”) owned, maintained, and serviced by third-party carriers, utilities, and internet service providers, all of which are beyond Saint Vil Medical Care Services LLC’s control. Saint Vil Medical Care Services LLC assumes no liability for or relating to the integrity, privacy, security, confidentiality, or use of any information while it is transmitted on the carrier lines, or any delay, failure, interruption, interception, loss, transmission, or corruption of any data or other information attributable to transmission on the carrier lines. Use of the Carrier Lines is solely at the Patient’s risk and is subject to all applicable local, state, federal, and international laws.
F. No Third-Party Beneficiary. No provision of this Agreement shall be construed to confer any third-party beneficiary rights to any non-party other than covered family members.
G. Supervening Circumstances. Saint Vil Medical Care Services LLC shall not be deemed in violation of any provision of this Agreement if it is prevented from performing any of its obligations by reason of: (a) severe weather and storms; (b) earthquakes or other natural occurrences; (c) strikes or other labor unrest; (d) power failures; (e) nuclear or other civil or military emergencies; (f) acts of legislative, judicial, executive, or administrative authorities; or (g) any other circumstances that are not within its reasonable control. This Section shall not apply to obligations imposed under applicable laws and regulations.
H. Compliance. Any provision of law or regulation or judicial or administrative interpretation of same that invalidates, or otherwise is inconsistent with the terms of this Agreement that, in the reasonable judgment of either party, would cause one or both parties to be in violation of law or regulation shall be deemed to have suspended the terms of this Agreement; provided, however, that the parties shall exercise their best efforts to accommodate the terms and intent of this Agreement to the greatest extent possible consistent with the requirements of law and regulations.
I. Severability. If any part, term or provision of this Agreement is held by a court of competent jurisdiction to be illegal or unenforceable, the remaining portions or provisions of this Agreement shall not be affected, and the rights and obligations of the Parties shall be construed and enforced as if this Agreement did not contain the particular part, term or provision held to be invalid, unless to do so would contravene the present valid and legal intent of the Parties.
J. Survival. All provisions of this Agreement that by their nature or express terms survive the expiration or termination of this Agreement, shall survive such expiration or termination.
K. Governing Law; Venue. This Agreement shall be enforced and construed in accordance with the laws of the State of Florida. Jurisdiction of any litigation with respect to this Agreement shall be in New York, with venue in a court of competent jurisdiction in Hillsborough County, Florida. The only information released shall be the minimum necessary. In any action, declaratory or otherwise, arising out of this Agreement, the prevailing party shall be awarded reasonable attorney’s fees and related costs to be paid by the other party.
L. Entire Agreement. This Agreement, including any exhibits or schedules annexed hereto, constitutes the entire understanding and agreement between the parties regarding all matters herein. There are no other agreements, conditions or representations, oral or written, express or implied, with regard thereto. This Agreement supersedes, in the entirety, any and all previous agreements, whether oral or written, between the parties concerning the subject matter hereof.
M.Counterparts. This Agreement may be signed in any number of counterparts, no one of which need by signed by more than one party, and all such counterparts, when duly executed, will be considered an original of one and the same document.
YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS:
AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.
Private Pay Agreement/Patient Service Agreement – Saint Vil Medical Care Services LLC/dba F.A.S. URGENT CARE CENTER
: All the information on this documents stays the same but we are offering only at this moment Telemed Membership for $150 yearly.
Frantz Saint Vil, CEO of Saint VIL Medical Care Serveces LLC