Terms & Conditions
This is an Agreement between Warrior Medical Group, (“Practice”), a Maryland LLC, located at 116 Defense Highway, Suite 200, Annapolis, Maryland 21401, and the persons listed in Appendix E (“Patient”). As described below, the Practice offers concierge healthcare: participating Practice patients receive a set of primary care and functional medicine services and optional testosterone replacement therapy (“TRT”) from Practice practitioners in exchange for a monthly fee. Please read carefully.
1. Services. As used in this Agreement, the term Services shall mean a package of ongoing primary care services and certain amenities that are offered by Practice and set forth in Appendix B.
2. Communication.
2.1 The Patient will be provided with methods to contact the Practice providers via phone, email, and other methods of electronic communication. The Patient consents to receive appointment reminders from Practice via e-mail or text. Practice shall not send any other information to Patient via e-mail or text to comply with the Health Insurance
Portability and Accountability Act (“HIPAA”) privacy requirements. Patient expressly waives the health care practitioners’ obligation to guarantee confidentiality with respect to appointment reminders sent via e-mail or text. All other communications between Patient and Practice staff shall be through a HIPAA compliant portal or via a telephone call.
2.2 Practice shall make a good faith effort to address the needs of the Patient in a timely manner, but cannot guarantee availability, and cannot guarantee that the Patient will not need to seek treatment in the urgent care or emergency department setting.
3. Fees. In exchange for the Services, Patient agrees to pay Practice the amount as set forth in Appendix A.
4. Non-Participation in Insurance. Patient acknowledges that neither the Practice nor the Practice’s licensed health care practitioners participate in any private health insurances or HMO plans. The Practice makes no representations whatsoever that any fees paid under this Agreement are covered by health insurance or other third-party payment plans. The
Patient shall retain full and complete responsibility for any fees charged by Practice. Any submissions for insurance reimbursement are between the Patient and Patient’s insurance company, according to the terms of Patient’s individual insurance contracts. The Practice’s role is limited to providing Patient with receipts for office visits with relevant billing codes.
There is no guarantee of reimbursement by the Patient’s insurance company.
5. Medicare. This Agreement acknowledges the Patient’s understanding that the Practice and the Practice’s licensed health care practitioners have opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for the Patient by the Practice’s licensed health care practitioners. The Patient agrees not to bill Medicare or attempt to obtain Medicare reimbursement for any such services. If the Patient is eligible for Medicare, or becomes eligible during the term of this Agreement, then the Patient will sign the Medicare Opt Out and Waiver Agreement attached as Appendix D and incorporated by reference. The Patient shall sign and renew the Medicare Opt Out and Waiver Agreement every two years, as required by law.
6. Insurance or Other Medical Coverage. Patient acknowledges that THIS AGREEMENT IS NOT A CONTRACT THAT PROVIDES HEALTH INSURANCE. It does NOT meet the insurance requirements of the Affordable Care Act and is not intended to replace any existing or future health insurance or health plan coverage that Patient may carry. It will not cover hospital services, emergency or urgent care services, ambulance services, skilled care, home care, specialist care or anything else not explicitly listed in Appendix B . Patient acknowledges that Practice has advised Patient to obtain or keep in full force such health insurance policy(ies) or plans that will cover Patient for general healthcare costs.
7. Term and Termination.
7.1 This Agreement will commence on the date it is signed by the Patient (“Effective Date”) for a term of one year. The Agreement will automatically renew each year on the anniversary date of the Agreement for a period of one year, unless either party cancels the Agreement by giving at least thirty (30) days written notice of cancelation.
7.2 Notwithstanding the above, both Patient and Practice shall have the right to terminate the Agreement without the showing of any cause for termination. This Agreement may be terminated upon at least thirty (30) days prior written notice to the either party (“30-day Termination Period”). If Practice notifies the Patient of termination, Practice shall provide the Patient with a list of other licensed health care practitioners in the community. Upon termination, Patient may continue to access Services until the last day of the 30-day Termination Period. If the termination is initiated by the Practice, no further charges will be assessed beyond the current billing cycle.
7.3 Upon mid-year termination (“Incomplete Term”), the Practice shall refund Patient the unused portion of Patient’s Monthly Membership Fee, as defined in Appendix A, paid during the Incomplete Term.
7.4 If Patient decides to re-enroll, the Practice reserves the right to deny re-enrollment.
8. Assignment. This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient.
9. Acceptance of Patients. Practice reserves the right to accept or decline Patients based upon its capability to handle appropriately the Patient’s primary care and TRTneeds. We may decline new patients pursuant to the guidelines set forth in Section 7 of this Agreement, because the Provider’s panel of patients are full, or because the Patient requires medical care not within the Practice’s licensed health care practitioners’ scope of services.
10. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Maryland and all disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for the Practice address in Annapolis, Maryland.
11. Payments. Payment shall be made by a recurring monthly credit or debit card charge. Fees will be charged according to the billing policies and procedures set forth in Appendix
A. If payment is not made timely, Patient will receive a written notice and, after at least thirty (30) days of non-payment, will be discharged from the Practice.
APPENDIX A
Enrollment and Membership Fees
This Agreement is for ongoing primary care and optional TRT. This Agreement is NOT HEALTH INSURANCE Practice is NOT A HEALTH MAINTENANCE ORGANIZATION. The Patient may need to use the care of specialists, emergency rooms, hospitals, specialists and urgent care centers that are outside the scope of this Agreement. Each provider within the Practice will make an appropriate determination about the scope of primary care services and optional TRT services offered by the Providers.
1. Enrollment Fee.
1.1 The Enrollment Fee is equal to two times the Monthly Fee for the Patient.
1.2 The Enrollment Fee is waived for children, defined as those individuals between the ages of 13-17, when a parent is enrolled or enrolling with the child. When at least one parent enrolls with a child, this is considered a Family Membership.
1.3 The Patient shall pay the Enrollment Fee on the Effective Date of this Agreement. The Enrollment Fee shall be paid using a credit/debit card entered into the electronic health record at time of enrollment. This fee is non-refundable.
2. Monthly Membership Fee.
2.1 The Monthly Membership Fee is for ongoing Services covered under this Agreement. Any service provided to Patient that is not included in the Monthly Membership shall be billed to Patient as an additional charge.
2.2 The Practice shall charge the Patient the Monthly Membership Fee at the beginning of the month using the credit/debit card on record in Patient’s electronic health record.
2.3 Primary Care Monthly Membership Fee is as follows:
2.3.1. Children ages 13-17:
2.2.1.1 $50/month with Family Membership
2.2.1.1 $150/month without Family Membership
2.3.2. Individual-Young Adult (age 18-25): $75/month
2.3.3. Individual-Adult (age 26 and up): $150/month
2.3.4. Married Couples: $275/month
2.2.5. Family Membership:
2.3.5.1. Rate is Individual Rate or Married Couple Rate plus $50 per child.
2.3.5.2 A Family Membership includes all individuals residing in the same household up to two adults and 4 children. Any additional children or adults will be charged as stated above.
2.4 Testosterone Replacement Therapy Monthly Membership Fee (“TRT Membership”):
2.4.1 Baseline testosterone replacement therapy: $350*/month.
2.4.2 TRT may enroll in the Primary Care Monthly Membership at no additional cost.
2.4.3 Primary Care Patients may elect to enroll into TRT Membership and the membership rate will increase to $350*/month
*This fee may vary based on agreed upon medications that are prescribed. This may increase based on the use of peptides or other adjunctive therapies.
2.5. Monthly Membership Fee Discounts.
2.5.1. Enrollment Fee may be waived at the discretion of the Practice during promotional events.
2.5.2. Selective Groups may receive a discount to their monthly membership fee to $125/month for individual membership, $250/month for couples membership, and $325/ month for testosterone replacement therapies. Selective groups may include military/veterans, police, fire fighters, EMS/first responders, educators and health care providers.
3. Additional Fees
3.1 Additional Fees for services that are not covered by the Monthly Membership Fee shall be disclosed to Patient prior to incurring the fee.
3.2 Additional Fees shall be paid by the Patient using a credit/debit card on record in the Patient’s electronic health record.
Appendix B: Services
The information contained in this Appendix B is subject to change and the most current version may be found on the Practice’s website. Changes to this Appendix B shall be regularly published by Practice on the website. Practice shall provide one electronic notification to Patient of such changes through the Practice’s electronic health record portal. Patient agrees to review such published changes on the website rather than by paper notification, and Patient acknowledges that Patient has read the website at the time of execution of this Agreement.
Primary Care Monthly Membership. Included Medical Services:
1.1 ;
1.2 Evaluation of new problems, including but not limited to treatment of sore throats, coughs, colds, other minor illness and injury;
1.3 Certain minor surgical procedures within the scope of practice of the treating health care practitioner;
Follow-up visits for the management of long-term medical conditions including, but not limited to, asthma, hypertension, diabetes and other chronic conditions/illnesses within the scope of Family Medicine;
Care coordination to assist Patient’s health team by organizing and forwarding pertinent information from primary exams for use by specialists including progress notes, laboratory results, and imaging reports.
TRT Monthly Membership.
The Practice will provide these therapies through consultation with the licensed health care practitioners.
These therapies may be considered off label use of medications.
Informed consent from the patient will be obtained prior to initiation of such therapies.
Additional fees may be incurred to cover the cost of therapy.
Non-Medical Services Included in Both Memberships
Access.
3.1.1 Patient shall have access to the Practice via direct telephone, email, text and video visits.
Non-urgent needs may be communicated by Patient during business hours or after hours and Patient shall receive a response from Practice within 2 business days.
Urgent Care.
Urgent needs shall be communicated by the Patient by calling the Practice office at (443) 203-8145 during office hours or by calling the private cell phone number for the Physician after office hours;
Patient agrees NOT to email or text urgent issues and shall instead call the office or the Physician directly.
If the Patient is having a life-threatening emergency issue, Patient shall call 911 or proceed directly to an emergency room.
After a telephone consultation with the Patient, the provider will determine, within his/her sole discretion, whether the illness or medical condition requires same-day care. If same-day care is warranted, arrangements will be discussed with the Patient to determine whether an office visit, phone visit, Urgent Care or Emergency Room visit is most appropriate. Cost for Urgent Care or Emergency Room visits is not included in the Monthly Membership Fee and shall be the responsibility of the Patient.
If same-day care is not warranted in the provider’s judgment, the Patient shall be scheduled for an appointment on the next available business day which is not a weekend day or holiday.
3.3 No Wait or Minimal Wait Appointments. Every effort shall be made to assure that Patient is seen by one of the Practice’s licensed health care practitioners immediately upon arriving for a scheduled office visit or after only a minimal wait.
Same Day/Next Day Appointments. Routine visits can be scheduled by calling the office or emailing the staff.
For acute issues requiring same/next day appointments, Patients can call the office prior to 12 noon on a normal office day (Monday through Friday) to schedule an appointment. Every reasonable effort will be made to schedule it the same day. If Patient calls after 12 noon for an acute/urgent issue, and if there is no availability that day, the visit will be scheduled the next business day.
Specialist Care/Referrals.
Practice shall refer Patient to a specialist when warranted, as determined by the treating provider.
If the Patient does not agree to follow through on a recommendation for specialist referral by the Practice, the Patient will be asked to sign an Against Medical Advice form. In the event of a refusal to sign, the Practice may exercise its right to terminate this agreement as set forth in Section 7 of the Agreement.
Although the Practice may help procure specialist cash pricing for the Patient as a courtesy, the Practice does not guarantee discounted specialist pricing. All financial relationships with specialists from whom Patient seeks care are the responsibility of Patient and not covered by this Agreement.
Limitations and Services Not Included in Monthly Membership
Ancillary Services. Ancillary services, such as laboratory testing, radiologic testing, and dispensed medications will be passed through “at cost” (no markup by Practice). Some ancillary services (such as EKGs) may be available in Practice office at no additional cost to Patient, as set forth on the Practice’s website and are subject to change.
Office Visits. Monthly Memberships include twenty-five (25) office visits per contract year. Each office visit over twenty-five will be charged a $20 per visit fee.
Virtual Visits. Monthly Memberships include unlimited virtual visits (e-mail, electronic, phone).
4.4. After-Hours Visits. There is no guarantee of after-hours availability. This agreement is for ongoing primary care and optional TRT, not emergency or urgent care. Patient’s provider will make reasonable efforts to see Patient as needed after hours if Patient’s provider is available.
4.5 In-Office Procedures. Any procedures performed in Practice office may incur an additional charge to Patient. Patient will be informed of this at the time of the appointment.
4.6 Point of Care Laboratory Studies. Studies may be performed in the office and the Patient may incur a small fee. Blood draws will be performed for laboratory studies at one of the local lab facilities
4.7 Prescriptions. Prescriptions are not included in the Monthly Membership Fee. Medications will be ordered in the most cost-effective manner possible for the Patient. The price of adjunctive therapies will be discussed with the Patient at the time of prescription.
4.8 Vaccinations. Vaccinations are NOT offered in Practice office at this time due to the cost prohibitive nature of stocking a limited supply. Practice will make an effort to help Patient obtain needed vaccinations elsewhere in the most cost-effective manner possible.
4.9 Hospital Services. Hospital Services are NOT covered under this Agreement. Practice does not admit Patients to hospitals. Practice will coordinate care with hospital physicians to help minimize unnecessary imaging and testing.
4.10 OBGYN. Obstetric and Gynecologic Services are NOT covered under this Agreement
4.11 Pediatric Services. Pediatric Services are limited to patients older than13 years of age. However, exceptions can be made on a case-by-case basis. Pediatric patients with complex medical management will be referred to the appropriate provider.
5. Controlled Substances. Warrior Medical Group, LLC, reserves the right to refuse to prescribe or refill controlled substances. Controlled Substances include, but not limited to, narcotics, benzodiazepines and stimulants. Patient agrees to notify Warrior Medical Group, LLC, immediately if any other providers prescribes Patient controlled substances. Warrior Medical Group, LLC, also reserves the right to perform random drug screenings to determine compliance with the prescribed treatment. An additional cost for the drug screening maybe charged to the patient. If a violation occurs, either noncompliance or multiple prescribers, Patient may be dismissed from Warrior Medical Group, LLC., at their discretion, with 30 days of emergency care and 90 days of any required medications apart from controlled substances. Patient will be informed via certified letter, as well as email, of this decision to terminate care.
APPENDIX D
MEDICARE PRIVATE CONTRACT
Provider Obligations
The Provider acknowledges that Provider is excluded from Medicare under sections 1128, 1156, 1892 or any other section of the Social Security Act. The Provider acknowledges that this contract shall not be entered into with the beneficiary, or the beneficiary’s legal representative, during a time when the beneficiary requires emergency care services or urgent care services, except that the Provider may furnish emergency or urgent care services to a
Medicare beneficiary in accordance with 42 C.F.R. § 405.440. The Provider acknowledges that Provider must retain this contract (with original signatures of both parties to this contract) for the duration of the opt-out period, and that it shall be made available to the
Centers for Medicare and Medicaid Services (CMS) upon request.
The Provider shall provide a copy of this contract to the beneficiary, or to his or her legal representative, before items or services have been furnished to the beneficiary under the terms of this contract. The Provider acknowledges that Provider must enter into a contract for each opt-out period.
Beneficiary Obligations
The beneficiary, or his or her legal representative, accepts full responsibility for payment of the Provider’s charge for all services furnished by the Provider.
The beneficiary, or his or her legal representative, understands that no payment will be provided by Medicare for items or services furnished by the Provider that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
The beneficiary, or his or her legal representative, understands that Medicare limits do not apply to what the Provider may charge for items or services furnished by the Provider.
The beneficiary, or his or her legal representative, agrees not to submit a claim, nor ask the Provider to submit a claim, to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare.
The beneficiary acknowledges that this written private contract contains sufficiently large print to ensure that the beneficiary is able to read this contract.
The beneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare
for their covered services, and that the beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out.
The beneficiary, or his or her legal representative, understands that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
The beneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the Provider during a time when the beneficiary requires emergency care services or urgent care services, except that the Provider may furnish emergency or urgent care services to a Medicare
beneficiary in accordance with 42 C.F.R. § 405.440.
The beneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the beneficiary, or to his or her legal representative, before items or services have been furnished to the beneficiary under the terms of this contract.
The beneficiary, or his or her legal representative, understands that during the opt-out period, a Medicare Advantage plan may not by law make any payments to the Provider for any Medicare items and services furnished to the beneficiary under this contract.