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Membership Plan Agreement

THIS MEMBERSHIP AGREEMENT (“Agreement”) is entered into by and between MAIN & VILLELLA, LLC, a Florida limited liability company d/b/a Rob Main Health and
Wellness (“Practice”) and the undersigned individual (the “Patient”).

Membership Plan. Patient hereby agrees to participate in the Practice’s direct primary medical care membership plan (“Plan”). Patient understands and agrees that this is a cash-only based Plan, and that participating in this Plan and in exchange for Plan Fees, Patient shall be entitled to receive the services described in Exhibit A (“Covered Services”), attached hereto and made a part of this Agreement, and shall be subject to the conditions and limitations described herein. Participation in this Plan is voluntary and includes only the Covered Services specifically described in Exhibit A. The Practice may add or discontinue Covered Services at any time, in its sole discretion. For the most up to date Membership Plan Agreement, visit the Practice’s website at https://robmainhealth.com/membershipplan.

  1. Term. This Agreement will commence on the date it is signed by the undersigned Patient and the Practice and shall be effective for a period of one (1) year. This Agreement shall automatically renew for successive periods of one (1) year unless either party terminates this Agreement as allowed under Paragraph 6.

  2. Covered Services. The Covered Services included in this Agreement are listed in Exhibit A, attached hereto, and incorporated herein. Patient acknowledgesthat practice offers NonCovered Services, otherwise referred to as Ancillary Services, which are not included in the scope of Covered Services identified in Exhibit A of this Agreement. Ancillary Services shall be priced and billed separately by the Practice and are not subject to the same rates or billing terms as the Covered Services outlined in Exhibits A and B.

  3. No Emergency Services. Patient expressly understands and agrees that the Practice does not provide any services for life threatening or emergency conditions. This includes but is not limited to chest pain/heart pain, paralysis of the limbs, inability to talk/slurring of words, dizziness or passing out spells. In the event of an emergency, or a situation in which the Patient could reasonably expect to develop into an emergency, Patient shall call 911 or go to the nearest emergency room. Patient further understands that the Practice’s provider(s) do not maintain hospital privileges or access.

  4. Plan Fees. In exchange for participation in the Plan, Patient agrees to pay a monthly Membership Fee (“Membership Fee”) in accordance with the Membership Fee Schedule published on the Practice’s website. Membership Fees are payable regardless of whether services are rendered each month. Patient understands the Practice has limited daily operating hours, as set forth in Exhibit B attached hereto and made a part of this Agreement. If Patient receives Covered Services during the days of the week, times, or by a method of delivery specified in Exhibit B as “Billable”, Patient understands an additional hourly rate fee will apply, as outlined in Exhibit B (the “Flex After Hours Fee” and/or “After Hours Fee”). These additional fees will be due and payable upon receipt of an invoice or as otherwise specified in this agreement. Patient is required to provide a credit card authorization as set forth in Exhibit C, attached hereto and made a part of this Agreement, in advance of receiving any Covered Services. Patient’s credit card will be charged the Membership Fee once per month and the Flex After Hours and/or After Hours Fees at the time the Flex After Hours and/or After Hours service(s) are rendered by the Practice or shortly thereafter.

  5. Not Insurance. Patient acknowledges and understands that this Agreement is for cash-only based services and does not provide comprehensive health insurance coverage, is not a contract of insurance, and is not regulated by the insurance laws of Florida. a. Insurance Claims. Patient acknowledges, agrees and understands that the Practice will not bill insurance companies on Patient’s behalf for Covered Services listed on Exhibit A and provided to Patient under this Agreement to any health care plan of which the Patient may be a subscriber or beneficiary for Fees due and owing to the Practice under this Agreement; this includes, but is not limited to, Medicare, Medicaid or commercially insured healthcare programs. Patient shall not submit claims or bills to any insurance company or health care plan seeking reimbursement for any services provided under this Agreement or for the reimbursement of Fees set forth herein. Because the Practice and the Patient are prohibited from submitting claims or bills to health care plans, the Fees incurred pursuant to this Agreement shall not be counted toward any deductible Patient may have under a high deductible health plan.

  6. Termination. Both Patient and Practice shall have the right to terminate the agreement without cause upon thirty (30) days prior written notice to the other Party, however, Patient shall not be able to provide such notice until completion of an initial ninety (90) day Term. Such notice shall be effective when notice is received at Patient’s email address on file or at Practices email address executiveteam@robmainhealth.com. Patient shall be responsible for any Fees incurred prior to termination. Upon termination, the Practice shall cooperate in the transfer of the Patient’s records to the Patient’s new provider upon the Patient’s written request.

  7. Communications. Patient acknowledges that communication with the Practice, its healthcare practitioner(s) or staff using e-mail, SMS/text messaging, facsimile, video chat, instant messaging, cell phone, including communications via the Practice’s preferred communication platforms which include but are not limited to Elation EHR, Spruce Medical and any other electronic health and/or communication platform the Practice may decide to use moving forward, are not guaranteed to be secure or confidential methods of communications. As such, Patient expressly waives the Practice’s, its Practitioners,’ and staff’s obligation to guarantee confidentiality with respect to correspondence using such means of communication. Patient acknowledges that all such communications may become a part of Patient’s medical records. By providing Patient’s e-mail address or SMS phone number, Patient authorizes the Practice, its Practitioners, or staff to communicate with Patient by e-mail or SMS, whether directly or through its selected communication platforms regarding Patient’s “protected health information” (PHI) (as that term is defined in Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulations). Patient acknowledges that:
    • a. E-mail, SMS/text messaging, facsimile, video chat, instant messaging, cell phone, whether directly or via the Practice’s preferred communication platforms, is not necessarily a secure medium for sending or receiving PHI and there is always a possibility that a third party may gain access;
    • b. Although the Practice, its practitioner(s) and staff will make all reasonable efforts to keep e-mail, SMS/text messaging, facsimile, video chat, instant messaging, cell phone, whether directly or via the Practice’s preferred communication platforms, confidential and secure, neither the Practice nor its practitioner(s) or staff can assure or guarantee the absolute confidentiality of such communications;
    • c. At the discretion of the Practice, its practitioner(s) or staff, e-mail, SMS/text messaging, facsimile, video chat, instant messaging, cell phone, whether directly or via the Practice’s preferred communication platforms, may be made a part of Patient’s permanent medical record, and
    • d. If Patient does not receive a response to an e-mail, SMS/text messaging, facsimile, video chat, instant message, cell phone call, whether directly or via the Practice’s preferred communication platforms, within one day, Patient agrees to use another means of communication to contact the Practice, its practitioner(s), or staff. Neither the Practice nor its practitioner(s) or staff will be liable to Patient for any loss, cost, injury, or expense caused by, or resulting from a delay in responding to Patient as a result of technical failures, including, but not limited to: (i) technical failures attributable to any interest service provider, (ii) power outages, failure of any electronic messaging software, or failure to properly address e-mail, voice mail or SMS messages, whether directly or through Practice’s preferred communication platforms, (iii) failure of the Practice’s computers or computer network, or faulty telephone or cable date transmission, (iv) any interception of communications by a third party; or (v) your failure to comply with the guidelines regarding use of e-mail, SMS/text messaging, facsimile, video chat, instant messaging, cell phone calls, whether directly or via the Practice’s preferred communication platforms, as set forth in this Paragraph.
    • e. Patient understands and agrees that e-mail, SMS/text messaging, facsimile, video chat, instant messaging, cell phone call, whether directly or via the Practice’s preferred communication platforms, is not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation in which the Patient could reasonably expect to develop into an emergency, Patient shall call 911 or go to the nearest emergency room.

  8. Notice to Medicare Patients. Patient acknowledges and understands that all healthcare providers associated with the Practice are opted out of Medicare, and as such, any and all Fees associated with the Patient’s receipt of the Covered Services are the sole financial responsibility of the Patient, even if he/she is a Medicare beneficiary and even if any of the Covered Services offered under the Agreement would otherwise be covered by Medicare.

  9. Indemnification. Patient agrees to indemnify and to hold the Practice and its members, officers, directors, agents, practitioners, and employees harmless from and against all demands, claims, actions or causes of action, assessments, losses, damages, liabilities, costs and expenses, including interest, penalties, attorney fees, etc. which are imposed upon or incurred by the Practice as a result of the Patient’s breach of any of Patient’s obligations under this Agreement.

  10. Entire Agreement. This Agreement constitutes the entire understanding between the parties hereto relating to the matters herein contained and if modified or amended the Patient will be notified in writing of any changes through our Patient communication platform Spruce.

  11. Governing Law. This Agreement and the rights and obligations of the Practice and Patient hereunder shall be construed and enforced pursuant to the laws of the State of Florida. If there is a change of any law, regulation or rule, federal, state or local, which affects this Agreement including its Exhibits incorporated herein by reference, or the activities of either party under the Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and either party reasonably believes in good faith that the change will have a substantial adverse effect on that party’s rights, obligations or operations associated with this Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms of this Agreement including its Exhibits. If the Parties are unable to reach an agreement concerning the modification of the Agreement within (30) thirty days after the effective date of change, then either Party may immediately terminate the Agreement by written notice to the other Party.

  12. Assignment/Binding Effect. This Agreement shall be binding upon and shall insure to the benefit of both the Practice and Patient and their respective successors, heirs, and legal representatives. Neither this Agreement, nor any rights hereunder, may be assigned by the Patient without written consent of the Practice.

  13. Patient Attestation. As indicated by my signature below, I understand and agree to the following:
    • I understand that this Agreement is for medical care/consultations and is NOT medical insurance.
    • I understand that the Practice will not file any third-party insurance claims on my behalf for services provided pursuant to this Agreement.
    • I understand that all healthcare providers affiliated with the Practice are opted-out of Medicare and Medicaid, and that as such all Fees associated with the Covered Services are my sole financial responsibility even if I have Medicare or Medicaid and even if the Covered Services would otherwise be reimbursable by Medicare or Medicaid.
    • I will not submit claims or bills to or seek any reimbursement from any health care plan that I might be part of, including claims for services covered under this Agreement or the Fee.
    • I agree to the Fees set forth in Exhibit A and for my credit card to be charged at the time of service or shortly thereafter.
    • I agree to the Cancellation and ‘No Show’ Policy set forth in Exhibit A, and for my credit card on file to be charged if I do not cancel at least 24 hours prior to my scheduled appointment or if I do not timely present to my appointment.
    • I understand that the Practice does not provide any services for life threatening or emergency conditions. In the event of an emergency, I agree to call 911 or go to the nearest emergency room. I further understand that the Practice’s provider(s) do not maintain hospital privileges or access.
    • I understand that this Agreement is non-transferrable.
    • I understand that I cannot list the Practice or its providers as a participating provider under any health insurance plans.

Exhibit "A" Covered Services

1. Covered Services.1

a. Medical Consultations and Advice for Care or Treatment;

b. Prescribing of Medications* as Medically Necessary;

c. Symptom Management of Chronic Conditions;

d. Receipt and Response to Patient Questions via Telephonic or Electronic Methods;

e. The following list of treatments:

  • i. Annual Physicals (Age 6-100)
  • ii. Sick or Urgent Care visits.
  • iii. Management of Chronic Illnesses
  • iv. Pap Smear/ Breast Exams
  • v. Sport Physicals
  • vi. Same or next day appts
  • vii. Labs/Phlebotomy
  • viii. EKG’s
  • ix. Injections
  • x. Suturing
  • xi. I&D’s
  • xii. IV’s2
  • xiii. Ear Wax removal
  • xiv. Lesion Removal
  • xv. Wart removal
  • xvi. Wholesale Rx’s
  • xvii. Wholesale Vaccines (BASED ON AVAILABILITY)
  • xviii. Holter Monitors
  • xix. Prior Authorizations for Rx & Diagnostic testing
  • xx. Joint Injections xxi. Splinting
  • xxii. Foreign Body removal
  • xxiii. Treatment of Corneal Abrasions
  • xxiv. Drug Screening
  • xxv. Sebaceous Cyst Removal3

1 The provision of Covered Services is limited to the states in which the Practice’s clinicians are licensed to practice medicine. If at any time, the Practice’s costs exceed the Practice’s budgeted allocation for any of the Covered Services, Patient may incur additional charges for such Covered Services, as solely determined by the Practice.

2 IV treatments are included in Covered Services only if recommended by a provider of the Practice in connection with a prior diagnosis or treatment plan. Any elective IV therapy requested by Patient is excluded and the provision of any such services will incur additional charges as set forth by the Practice in its sole discretion.

2. Receiving Covered Services.

  • a. Office Visit: For the purposes of receiving an office visit (whether it is in in-person or via telemedicine) a Patient must schedule and pre-book such visit in advance with the Practice to ensure availability. If the Practice travels to a Patient’s home to provide such Covered Services, Patient will be charged for the Practice’s actual round-trip travel time incurred, billable in 15-minute increments, at the applicable Fee rates set forth in Exhibit B.

  • b. Submission of Questions (via phone or electronic): A Patient may submit medical related questions to the Practice to be answered by the Practice at the Practice’s availability to do so. The Practice will strive to respond to such questions within 24-hours of receipt but is under no obligation to do so; the Practice will inform the Patient if its response time will be longer due to Practice emergency or other unforeseen unavailability.

3. Office Visit Cancellation & “No Show” Policy. The Practice requires that all scheduled Office Visits (whether in-person or via telemedicine) are cancelled at least 24-hours in advance of the time that was booked by the Patient.

If Patient does not cancel Patient’s booked Office Visit at least 24-hours in advance or does not timely arrive for their appointment, Patient’s credit card on file will be charged a ‘no show’ fee of $75.00.

Exhibit "B" Plan Fee Schedule

The Plan’s Fee Schedule (“Plan Fees”), include the monthly Membership Fee, in addition to the following, as applicable:

DAY(S) Membership Plan Hours (Covered Services) Flex After Hours (Limited Covered Services) After Hours (Billable) After Hours Rates and Fees
M-F 8am EST-5pm EST (Scheduled Visits, Text, Phone or Telemedicine are Covered) *In Home Care and Unscheduled Office Visits are Billable 5pm EST-9pm EST (Only Text, Phone or Telemedicine are Covered) *In Home Care and Office Visits are Billable 9pm EST-8am EST *Everything is Billable $400.00 per hour, billable in 15-minute increments.
Weekend N/A 8am EST-12pm EST (Only Text, Phone or Telemedicine are Covered) *In Home Care and Office Visits are Billable 12pm EST-8am EST *Everything is Billable $400.00 per hour, billable in 15-minute increments.
National Holidays N/A N/A 24 Hours *Everything is Billable $400.00 per hour, billable in 15-minute increments.

If Patient does not cancel Patient’s booked Office Visit at least 24-hours in advance or does not timely arrive for their appointment, Patient’s credit card on file will be charged a ‘no show’ fee of $75.00.

The Practice’s Fee Schedule, including its Membership Fee and Flex After Hours and After Hours Fees, are subject to an annual increase in the amount of five percent (5%) per annum, or the most recent United States Bureau of Labor Statistics Consumer Price Index, whichever is greater. For the most up to date Membership Agreement and Fee Schedule, visit the Practice’s website at https://robmainhealth.com/membershipplan.

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(352) 282-0010