CIAMPI FAMILY PRACTICE DIRECT PRIMARY CARE AGREEMENT
I, ___________________________(PATIENT) agree to enroll myself and/or members of my household (listed below) into a direct primary care subscription with Michael A. Ciampi, M.D. and Ciampi Family Practice. I understand that in doing so, I/we will receive medical services normally provided in a family physician’s office as part of the subscription agreement. Specific examples of what is and is not included are listed below. This is not a comprehensive list, so please feel free to inquire about other services and whether or not they are provided in our office and if they would be covered under the agreement.
What is included?
- Annual physical/wellness exams
- Office visits for chronic disease (diabetes, high blood pressure, depression, asthma, etc)
- Office visits for acute illnesses and injuries, as well as general health questions.
- Services required for diagnostic testing that can be done in our office:
- Spirometry (breathing tests)
- Nebulizer (breathing) treatments
- Ankle/Brachial Index testing (screening for artery blockages in legs)
- Hemoglobin A1C testing (fingerstick blood test for monitoring of diabetes)
- Urine dipstick testing, including pregnancy tests, drug screening
- Fingerstick screening for anemia
- Some joint injections
- Minor skin procedures (draining abscesses, biopsies)
- Freezing of warts, skin tags, and precancerous lesions
- Access to your personal physician in the office, and via e-mail, as well as via other electronic communication modalities if and when available. Enrolled patients are given a private e-mail address to which they can send non-urgent messages, as well as telephone number(s) to which they can call or send text/SMS messages. Patients are reminded that use of non-encrypted e-mail is not necessarily secure. Use of e-mail implies consent for response, which also may or may not be encrypted.
- Significant discounts on laboratory testing on any blood, urine, or other samples which we must send to an outside lab. We provide these tests to our patients at our cost plus a $10.00 draw fee.
- Discounted generic medications. We stock several generic medications in our office which we will offer to our subscription patients. Medications are charged at our wholesale cost plus 10%. On a case by case basis, we can order medications for patients if we do not have them in stock. Ciampi Family Practice is not, nor ever will be a retail pharmacy. We do not dispense medications to patients who are not in our practice, nor will we fill prescriptions written by doctors other than Dr. Michael Ciampi. We do not sell controlled medications (pain killers, tranquilizers, etc.) to patients. We do not prescribe medical marijuana
- As long as standard vaccinations for children residing in Maine are supplied by the State of Maine there is no additional cost to our patients for them. For adults, we can provide the vaccines at our wholesale cost.
- House calls done within 10 miles of 380 Lincoln Street, South Portland, ME are done at an additional charge of $100.00 per visit. Additional charges may apply if outside this area.
What is not included?
- X-rays, CT scans, MRIs, colonoscopies, or any other tests that are performed outside of our office.
- Consultations with specialists.
- Hospital and nursing home visits. While Dr. Ciampi does not make hospital or nursing home rounds, he is happy to coordinate care with the house doctors during your stay at a facility to make the transition back home smoother.
- Legal proceedings. In the rare instances where a service such as a deposition or other legal consultation is needed, we are happy to negotiate a special rate with your attorney.
TERM OF AGREEMENT:
This agreement will be effective on the date it is signed by the patient. It will be considered in effect for one year from the date of enrollment. Unless either the patient or Ciampi Family Practice gives 30 days notice that they wish to terminate the agreement prior to that date, the contract will automatically renew each coming year.
The minimum commitment expected is 3 months. Payment for the initial 3 months will be charged at the initial visit of the first family member to be seen.
The patient agrees to one of the following payment schedules:
- Annually, with the benefit of receiving 12 months of service for the price of 11 months. ($550/individual, $1045/couple, $1540/family)
- Every six months, ($300/individual, $570/couple, $840/family)
- Quarterly ($150/individual, $285/couple, $420/family)
- Monthly ($50/individual, $95/couple, $140/family). We require a minimum 3 month commitment.
In the event that rates change, the patient would be given at least 30 days notice prior to the date of their automatic renewal.
A family consists of one or two parents and all non married children living in the home who are under age 26.
Please note that there will be a $25 fee assessed to the patient for a check returned due to insufficient funds.
Ciampi Family Practice reserves the right to offer discounted rates at their sole discretion.
Either party may terminate this contract, given 30 days notice to the other party after the initial 3 months of the membership.
In the event that the patient elects to cancel membership and had pre-paid for months in advance, they will receive a prorated refund. It will consist of a refund of fees for each whole month of services that will not be used thirty (30) days after date of receipt of the notice to cancel. From that sum, we will deduct the fair market value of any services already rendered. If a patient has pre-paided for 12 months of service for the price of 11 months, they will not receive a refund for the last month’s service, which would have been free.
In the event that the patient elects to cancel membership and is paying monthly, they agree that payments will be discontinued at the end of the next calendar month.
If a patient cancels membership within the first three months of membership and has already had a visit, the subscription fee for the first three months will not refunded because the value of the initial visit is equal or greater than that payment.
TERMINATION FOR NON-PAYMENT:
In the event a patient’s account becomes delinquent, they will be notified by telephone, by mail, or electronically of this situation. If Ciampi Family Practice does not receive payment, or the patient and Ciampi Family Practice do not reach a mutually satisfactory arrangement to resolve the situation within thirty (30) days of said notice, it will be assumed that the patient no longer wishes to be a patient of Ciampi Family Practice. At that point, the patient may be discharged from the practice. Said discharge will be in accordance with all applicable Maine regulations and statutes.
There is no initiation fee for new patients entering into the initial agreement for subscription medical services at Ciampi Family Practice. There is a reinstatement fee for patients who have intentionally or unintentionally allowed their membership to lapse, or have cancelled it, assuming that Ciampi Family Practice agrees to resume the patient’s care. That fee will be a non-refundable $200 per single patient, $400 per couple, or $500 per family, or the total balance of fees for the lapsed months, whichever is less, with a minimum of three months commitment.
UNDERSTANDING THAT SUBSCRIPTION IS NOT HEALTH INSURANCE:
The patient(s) understand that the services provided by Ciampi Family Practice do not constitute health insurance.
A Direct Primary Care membership by itself does not meet requirements of any federal law mandating individuals to purchase health insurance.
The membership fees charged by Ciampi Family Practice may or not be reimbursed or apply towards a deductible under a health insurance policy with an insurer.
This agreement is a personal service contract/retainer with your personal physician. Ciampi Family Practice strongly encourages patients to have some time of health insurance plan to cover catastrophic medical expenses. Types of plans may include, but are not limited to: commercial health insurance policies, faith based health sharing ministries, Medicare, or other government funded insurance. We also recommend that patients with high deductibles consider funding a Health Savings Account (HSA) to cover out of pocket expenses up to the deductible.
NON-PARTICIPATION WITH INSURANCE AND MEDICARE:
Ciampi Family Practice does not participate in any insurance company’s network and does not submit claims to insurance. We cannot make any guarantees about patients receiving reimbursement from any insurance company should they submit receipts to said company.
Michael Ciampi, M.D., and Ciampi Family Practice have opted out of Medicare. If a patient is a Medicare beneficiary, or will become one soon, in order to enroll as a patient of Ciampi Family Practice, they must sign an additional agreement stating specifically that they understand that no services provided can be reimbursed by Medicare. If signed prior to April 1, 2017, this additional agreement will need to be renewed two years from date of the the original agreement. This agreement applies only to services provided by Dr. Ciampi and Ciampi Family Practice. It in no way limits services they may receive from other providers who accept Medicare. If the patient has blood or other samples taken by personnel at Ciampi Family Practice that is sent to an outside laboratory, Ciampi Family Practice can send pertinent information to that facility so that they can bill Medicare on the patient’s behalf. The same is true for diagnostic or therapeutic procedures and tests done outside Ciampi Family Practice, such as, X-rays, CT scans, MRIs, colonoscopies, and specialty consultations. This also applies for durable medical equipment, visiting nurses, and oxygen. Those vendors should be able to bill Medicare directly on the patient’s behalf.
NUMBER OF VISITS PER YEAR:
While there is no predetermined limit to the number of visits per year, Ciampi Family Practice does reserve the right to have a discussion with individuals who have unexpectedly high use of services to determine appropriateness of care and if a modified arrangement may be appropriate. Medical services are provided as deemed medically necessary by Ciampi Family Practice.
During times when Ciampi Family Practice is closed, on nights, weekend, holidays, and vacations, there is always a physician available by telephone. We ask that contacting the physician on call be done only for matters which cannot wait until the office re-opens. For less urgent matters, there is an option to leave a voicemail which will be answered promptly at the start of the next business day. Patients may also send non-urgent e-mails that are answered promptly as well.
All office visits are by appointment only. We are not a walk-in clinic nor an emergency room. We ask that patients please call ahead before coming to the office if they do not have an appointment.
If you have an injury or illness that threatens life or limb, please call 911 or proceed to the nearest emergency room!
From time to time, due to vacations, illness, or personal emergency, Dr Ciampi may be temporarily unavailable. In order to assist patients in scheduling non-urgent visits, Ciampi Family Practice will notify patients of any planned physician absences as soon as the dates are confirmed. Should Dr. Ciampi have an absence, Ciampi Family Practice will make every effort to triage calls and/or direct patients to a physician who can provide coverage and/or care. The patient may or may not have to pay the covering physician for their services as they fall outside of this agreement.
CHANGE OF LAW:
If there is a change of any relevant law, regulation, or rule, federal, state, or local, which affects the terms of this Agreement, the patient and Ciampi Family Practice agree to amend this Agreement to comply with the law.
Enrollees: ________________________ __________________________