Concierge Membership Sign Up

Patient Acknowledgment and Agreement

1. Exclusions from Program Services

   The Patient understands and agrees that Program Services do not include hospital services, emergency care, surgery or surgical-related services, radiology or imaging services, third-party provider services, or certain laboratory services. These services are not covered by the Membership Fee and may be billed separately by outside providers.

   The Membership Fee for each Renewal Year must be paid in full prior to the start of the renewal period. Any other invoiced charges must be paid in full, or authorized for automatic payment, within thirty (30) days of the invoice date.

   If this Agreement is determined to be invalid by a court or regulatory authority and a refund of any Membership Fee is required, the Patient agrees that the Practice may retain or collect an amount equal to the reasonable value of any Program Services including administrative and processing fees provided prior to the refund.

2. Excluded Health Care Services The Membership Fee and Visit Fee cover the cost of Program Services, but do not include health care services covered by insurance. The Physician and Practice make no representations regarding insurance coverage for any fees paid under this Agreement. The Patient remains financially responsible for any health care services not covered by their insurance.

3. Insurance or Medical Coverage
   The Patient acknowledges that this Agreement is not an insurance plan and does not substitute for health insurance or other coverage. The Patient is advised to maintain suitable health insurance policies for general healthcare needs. The Program Services provided under this Agreement are not covered by Medicare, Medicaid, or any other third-party payer, and the Practice and Physician have opted out of Medicare. If the Patient is or becomes eligible for Medicare, they acknowledge that the Physician cannot bill Medicare for any services rendered.

4. Designated Physician
   Program Services will be provided by the designated Physician, who may, at times, designate a qualified covering physician or licensed medical professional. The Practice will offer appointments on a first-come, first-served basis, with exceptions for urgent medical needs as determined by the Physician.

5. Term and Termination

   This Agreement has an initial term of one (1) year commencing on the Effective Date and renews annually unless either party provides written notice of non-renewal at least 30 days prior to the end of the then-current term.

   Early Termination by Patient.
   The Patient may request termination with thirty (30) days’ written notice; however, early termination does not relieve the Patient of the financial obligation for the full one-year term. All remaining amounts due for the remainder of the term shall remain payable according to the payment schedule, unless expressly waived in writing by the Practice.

   Relocation.
   If the Patient permanently relocates outside the Practice’s service area, the Agreement may be terminated upon written notice; however, any outstanding financial obligations accrued through the termination date shall remain due, unless otherwise stated in writing by the Practice.

   Termination by Practice.
   The Practice may terminate this Agreement for material breach or non-payment, or for any other reason upon thirty (30) days’ written notice. If terminated by the Practice for reasons other than Patient breach or non-payment, the Patient shall receive a prorated refund for prepaid, unused services.

   Automatic Termination.
   This Agreement shall terminate automatically upon the death or dissolution of either party.

6. Communications The Patient authorizes the Physician and Practice staff to communicate via electronic means (such as email, text, and the patient portal) regarding protected health information (PHI). Electronic communication is not guaranteed to be secure, and the Patient acknowledges that PHI may be part of their medical record. Emergency and sensitive medical issues should not be communicated electronically; instead, the Patient should seek immediate medical attention.

7. Independent Medical Judgment
   The Physician retains full discretion to make medical decisions in the best interest of the Patient, and nothing in this Agreement should influence or limit the Physician’s independent medical judgment.

8. Amendments and Changes
   The Practice may amend this Agreement as necessary, including in response to changes in law. The Patient will be notified of such changes, which will become effective upon notice. Any other amendments must be made in writing and signed by both parties.

9. Governing Law and Dispute Resolution
   This Agreement will be governed by Texas law. Any disputes will be resolved exclusively through binding arbitration in Harris County, Texas, under the rules of the American Arbitration Association. Both parties waive their right to a jury trial.

10. Severability
    If any part of this Agreement is found to be invalid or unenforceable, the remainder of the Agreement will remain in effect.

11. Notice
    All communications related to this Agreement (except those regarding PHI) should be sent in writing to the addresses listed in this Agreement. Changes in address must be communicated according to these provisions.

12. Legal Significance
    The Patient acknowledges that this Agreement is a legally binding document and has had the opportunity to seek legal advice.

13. Entire Agreement
    This document constitutes the entire agreement between the parties, superseding all prior agreements. Any terms of usage designated by the Practice will take precedence over conflicting terms in this Agreement.

By signing below, the Patient agrees to all terms and conditions outlined in this Agreement.