Member Contract

• General Agreement and Services

  ·         I acknowledge and understand that I am voluntarily becoming an Equinox Primary Care, LLC (“Equinox”) patient and that this agreement is non-transferable.

  ·         I have reviewed the services provided and not provided by Equinox and I have had the opportunity to ask questions and receive answers regarding this.

  ·         I acknowledge and understand that this agreement does not provide for comprehensive health insurance coverage nor is it a contract of insurance and that it provides only the health care services specifically listed on the Equinox website.

  ·         I acknowledge and understand that Equinox may add or discontinue services or may increase my fee schedule at any time (but no more than once per year), and that I will be given, in writing, at least sixty (60) days’ notice of such fee schedule changes.

  ·         I understand that I have the right to receive accurate and easily understood information about Equinox’s health care services, health care professionals and health care facilities. If I speak a language different from my clinician, have a physical or mental disability or do not understand something, I understand that Equinox will make its best effort to provide assistance so I can make informed health care decisions. If I require interpreter services beyond what can be provided by Equinox, professional interpreters may be provided at an additional cost to me.

  ·         I understand that I have the right to considerate, respectful, and nondiscriminatory care from my Equinox health care clinician(s). I also understand that I am responsible for communicating clearly and respectfully with my clinician. Should I become dissatisfied with my care or Equinox services, I agree to notify Equinox immediately so my concerns may be addressed in a timely manner.

  ·         I understand that I in turn am obligated to treat Equinox staff and other members with consideration and respect and avoid threatening of abusive language or behavior. Such behavior may be grounds for placement on probationary membership status or immediate termination of membership, at the sole determination of Equinox staff.

  ·         I understand that I have the right to know all my treatment options and to participate in my health care decisions. Parents, guardians, family members or other individuals whom I designate may represent me if I cannot make my own decisions.

  ·         To receive the best possible care, I agree to be actively involved in my health care decisions and to disclose all relevant information to my Equinox health care clinician(s) so that they can help me achieve my health goals. I also agree to inform my Equinox health care clinician(s) of any healthcare services I receive outside of Equinox (such as emergency room, specialist, or hospital services).

  ·         I understand that I am responsible for not exposing myself or others to disease or danger. I understand that I can receive information from my Equinox health care clinician(s) about protecting the health and safety of myself and others.

   

  Payment

  ·         I acknowledge and understand that I am responsible for any charges incurred for health care services performed outside of Equinox including but not limited to emergency room, hospital and specialty services and that Equinox will not bill insurance carriers for any services provided by Equinox.

  No-Show Policy

  ·         I acknowledge and understand that I must provide at least 24-hour advance notice of any appointment cancellations.  In case of emergency, I will contact the office as soon as I am able to acknowledge the missed appointment and arrange to reschedule.  Chronic no-shows or late cancellations of appointments decrease access for other patients and may be grounds for membership termination by Equinox.

  Privacy

  ·         I understand that I have the right to speak in confidence with my Equinox provider(s) and to have my health care information protected. I understand that Equinox will not disclose my information without my authorization or without a legal obligation to do so. I also understand that I have the right to review and receive a copy of my personal medical record and may request that my health care provider(s) amend my record if I feel it is inaccurate or incomplete by contacting Equinox and requesting such an amendment.

  ·         I acknowledge and understand that Equinox must maintain a record of my health information and must protect the privacy of my health information as per the terms of the Notice of Privacy Practices. I understand and acknowledge that this policy is available for my review at any time upon request.

  Termination

  ·         I acknowledge and understand that I may terminate this Patient Agreement at any time and for any or for no reason by providing written notice to Equinox. Monthly fees will continue to accrue until written termination notice is received. Any pre-paid monthly care fees will be prorated to the date Equinox has received my written termination and refunded to me within ten (10) business days.  I understand that if my account is overdue, I am responsible for resolving the outstanding balance prior to my service cancellation.

  ·         In addition, I acknowledge and understand that Equinox may terminate this Patient Agreement by providing me written notice and any pre-paid monthly care fees will be prorated to the date of termination and refunded to me within ten (10) business days. Equinox will not terminate this Patient Agreement solely on the basis of health status.

  Medicare Beneficiaries

  ·         I acknowledge and understand that if I am enrolled in Medicare I will receive a copy of the Medicare Opt-out Agreement for review and signature before my first appointment. (The Opt-out Agreement does not prevent me from receiving current or future Medicare benefits from non-Equinox providers; neither I nor my Equinox healthcare provider(s) will seek reimbursement from Medicare for the medical services I receive from Equinox.)

  Complaints

  ·         I understand that I have the right to a fair, fast and objective review of any complaint I have against my physician or any other staff, including complaints about wait times, operating hours, conduct of personnel, business practices, and adequacy of health care services and facilities.

  ·         I agree to first bring any complaints to the attention of Equinox staff and to participate in the Equinox complaint and grievance process. Unresolved complaints may be brought to the attention of the Office of the Insurance Commissioner for the State of Washington by calling the Consumer Advocacy department at: (800) 562-6900 (TDD 360-586-6241) or by email at cad@oic.wa.gov.

  Telehealth Use Consent

  ·         Telehealth involves the use of live audio-video or other forms of synchronous and asynchronous electronic communications to deliver health care services to patients while the health care provider (Provider) is located at a physical location different from the patient receiving the health care services (Telehealth Services).

  ·         By agreeing to receive Telehealth Services from Equinox Primary Care PLLC via phone, video, or electronic communications, I acknowledge that:

  1.      There are potential risks to using electronic communications for the purpose of a health care visit, including, but not limited to, service interruptions, unauthorized access, technical difficulties, call termination or other equipment failures. I acknowledge and accept those risks, understanding there are alternatives to receiving Telehealth Services.

  2.      I may receive protected health information via email or SMS text messaging. I understand that messages shared through these communication channels may not be secure in every instance.

  3.      Either I or the Provider can discontinue Telehealth Services if either of us determines that Telehealth Services are not right for my health care.

  4.      It is my responsibility to provide accurate, complete, and current information about me and my health condition(s) to the Provider while receiving Telehealth Services.

  5.      The Practice has made reasonable and appropriate efforts to eliminate any confidentiality risks associated with Telehealth Services. I am also responsible for reducing any risks to my privacy or confidentiality resulting from the location or circumstances of my participation in Telehealth Services (e.g., joining the telehealth encounter from a quiet space, ensuring others do not overhear my conversation or see my computer or mobile device screen). All existing confidentiality protections under federal and state law apply to my information disclosed during Telehealth Services.

  6.      I understand and acknowledge that Telehealth Services are not intended to be, and do not act as, emergency services. If I am experiencing an emergency, I should not rely on Telehealth Services and instead should call 911 or go to an emergency department.

  7.      I understand what it means to receive Telehealth Services and am legally authorized to acknowledge, agree, and consent to the use of Telehealth Services.

  8.      I am responsible for all charges (a) that I may incur from my mobile or internet service provider, as applicable, when receiving Telehealth Services.

  ·         By becoming a patient of Equinox Primary Care, PLLC, I, the patient, hereby represent that I have read and understand this Consent to use Telehealth Services and the anticipated benefits and risks of the use of telehealth provided to me and consent to receive Telehealth Services from Equinox Primary Care.

   

  Equinox Primary Care Financial and No-Show Policies

  Revised June 2021

   

  In order to keep overhead costs and membership fees down, the following financial and no-show policies apply to all members of the practice:

   

  Method of payment

   

  ·         Individual members must keep a reliable method of payment on file, either a bank account or credit/debit card.  It is the member’s responsibility to keep this payment method current.  Our billing system will send out automatic notifications if a payment does not go through, and patients are expected to respond to those notifications and correct the payment method (members must sign the HIPAA agreement with our billing software in order to receive notifications; maintaining an up to date email is the member’s responsibility). 

   

  Late and Non-Payment

   

  ·         If fees are not paid within 30 days of the due date, members will be notified of the delinquency and are at risk of suspension if not paid in full by 60 days and termination if not paid in full by 90 days. 

   

  ·         If terminated, members may not be eligible for reinstatement in the practice, and the practice reserves the right to reinstate at its discretion.

   

  Financial Hardship

   

  ·         If you are unable to pay your fees on time, please contact the office at least 2 business days prior to your scheduled payment date to make arrangements.  Members who are experiencing financial hardship are encouraged to contact the office to discuss; accommodations are made on a case-by-case basis. 

   

  No-shows and Late Cancellations

   

  ·         Members who no-show or late cancel (less than 24 hours’ notice) 3 times will be subject to scheduling restrictions and possible termination.

   

  ·         If cancelling your appointment 24 hours or less prior to an appointment, please text or call the office so that we can open up the schedule to other patients.