THIS SERVICE AGREEMENT (the “Agreement”)
is entered into as of the “Effective Date” above by and between the
Subscriber listed above (“SUBSCRIBER”), and ACT Physician Group, P. A.,
a Texas professional association that conducts a professional medical practice,
including urgent care services, at various locations in and around Amarillo,
Texas, known as the Care Today Clinics (“CARE TODAY”).
In
consideration of the representations, covenants and agreements contained in
this Agreement and the attached Exhibits, SUBSCRIBER and CARE TODAY agree as
follows:
1.
Services.
1.1.
CARE TODAY will provide the
standard medical services (“Standard Services”) set forth on Exhibit “A”
attached hereto to the SUBSCRIBER and his/her family members designated
above (SUBSCRIBER and listed family members referred to collectively as “Covered
Persons”) for a fixed price each month as set forth in the above table of
“Monthly Base Fees.” SUBSCRIBER will provide information regarding Covered
Persons on the Enrollment Form provided by CARE TODAY.
1.2.
CARE TODAY will also provide
additional medical services (“Additional Services”) to Covered Persons
at CARE TODAY’s usual charge for such services. Additional Services shall
include any services provided by CARE TODAY not included in Exhibit “A”
attached hereto. CARE TODAY shall have sole discretion to determine whether
specific services are Standard Services or Additional Services. CARE TODAY
shall also have the right to add new services, from time to time, to the Standard
Services or Additional Services.
2.
Term.
2.1.
The initial term of this Agreement
will be for one year from the Effective Date.
2.2.
At least ninety (90) days before
the end of the then current term, CARE TODAY will provide to SUBSCRIBER the
monthly base fee for the selected plan for the Standard Services to be provided
under this Agreement for the next year. This Agreement will automatically
renew for a successive additional one year term, at such new monthly fees,
unless either party gives the other written notice at least sixty (60) days
before the end of the then current term.
2.3.
Notwithstanding the foregoing and
except as provided in Paragraph 3.4 below, this Agreement can be terminated at
any time on written notice for cause consisting of a material breach of a term
or condition hereof which is not corrected within forty-five (45) days of
receipt of a written notice describing the breach in reasonable detail. This
Agreement may also be terminated on written notice in the event CARE TODAY
becomes legally unable to provide the services contemplated herein.
3.
Fees.
3.1.
Upon execution of this Agreement,
SUBSCRIBER agrees to pay CARE TODAY a monthly base fee for each Covered Person,
which amount will be adjusted yearly, for providing the Standard Services to
Covered Persons of SUBSCRIBER (the “Base Fee”). CARE TODAY agrees to
begin providing such Standard Services to Covered Persons on the first business
day of the month following the date of execution of this Agreement.
3.2.
On or before the first business day
of each subsequent month during the term of this Agreement, SUBSCRIBER agrees
to pay CARE TODAY the Base Fee for each Covered Person. SUBSCRIBER hereby
authorizes CARE TODAY to process payment by Credit Card or Bank Draft, as
authorized above, and SUBSCRIBER shall execute such additional documents as may
be requested by CARE TODAY to approve and implement such form of payment.
3.3.
Unless otherwise agreed by
SUBSCRIBER, all charges for Additional Services will be the responsibility of
SUBSCRIBER and/or Covered Person. Payment for such Additional Services shall
be made at the time of the rendition of such services.
3.4.
Notwithstanding anything to the
contrary in this Agreement, CARE TODAY will have the right to terminate this
Agreement immediately if SUBSCRIBER defaults on its payment obligations of any
amounts due under this Paragraph 3 and such payment default is not cured within
ten (10) days after CARE TODAY delivers written notice of such default to
SUBSCRIBER.
3.5.
The parties acknowledge and agree
that CARE TODAY will not bill any health plan, federal health care program or
other payor for any Standard Services provided hereunder and included in the
Base Fee.
4.
Patient Privacy.
5.1 CARE TODAY will protect the privacy and
confidentiality of all patient information, in accordance with applicable
federal and state law and CARE TODAY’S Notice of Patient Privacy Practices, a
copy of which has been provided to SUBSCRIBER.
5.
Termination Procedures.
5.1.
In the event this Agreement is
terminated, for whatever reason, or expires, CARE TODAY will continue to
provide services under this Agreement for the period of time for which
SUBSCRIBER has made actual payment pursuant to Paragraph 3 above.
5.2.
Except for the foregoing or for
such other matters as the parties may agree to in writing, after the effective
date of termination, CARE TODAY shall have no further obligations to provide
services to Covered Persons under this Agreement.
6.
Notice.
6.1.
Any notices, payments, demands or
communications required or permitted to be given by the provisions of this
Agreement will be effective on the date when deposited in postage prepaid,
certified or registered mail, return receipt requested at the following
addresses: (1) If to SUBSCRIBER, then the SUBSCRIBER’S address from Page 1 of
this Contract. (2) If to CARE TODAY, then 7118 I-40 West Bldg D, STE 500,
Amarillo, TX 79106.
7.
Disputes.
7.1.
ALL PARTIES TO THIS AGREEMENT
AGREE THAT ANY DISPUTE, CONTROVERSY OR CLAIM ARISING OUT OF, RELATING TO OR
CONCERNING THIS AGREEMENT, BREACH OF THIS AGREEMENT OR SERVICES PROVIDED
PURSUANT TO THIS AGREEMENT, SHALL BE SUBMITTED TO AND SHALL BE SETTLED
EXCLUSIVELY BY BINDING ARBITRATION.
7.2.
The arbitration proceeding shall
be conducted by a single arbitrator and shall be governed by the then current
Commercial Rules of the American Arbitration Association (“AAA”) and, to the
extent not inconsistent with such Commercial Rules, by the terms of the Federal
Arbitration Act (9 U.S.C. §1, et seq.). The parties agree that this Agreement
relates to interstate commerce and that the Federal Arbitration Act applies to
this Agreement. If, for some reason, it is determined that the Federal
Arbitration Act does not apply to this Agreement, then the Texas Arbitration
Act (Texas Civil Practices & Remedies Code Sec. 171.001 et seq) shall
apply.. Notwithstanding the foregoing, the parties ADOPT the AAA Commercial
Rules EXCEPT to the extent indicated below or expressly set forth elsewhere in
this Agreement:
7.2.1.
Rule R-7(a) is not adopted.
Instead, the parties stipulate and agree that the AAA has jurisdiction over any
disputes that arise between them under this Agreement. Neither the AAA nor the
arbitrator has the authority to declare that this Agreement is not subject to
arbitration. Neither the AAA nor the arbitrator may suspend, abate or delay
arbitration under this Agreement in the absence of an order of a court of
competent jurisdiction expressly requiring the suspension, abatement or delay
of arbitration under this Agreement. Any party seeking an order from a court
of competent jurisdiction for the suspension, abatement or delay of arbitration
under this Agreement will be liable for all costs, including attorneys’ fees,
incurred by the other party in connection with any such court proceeding,
regardless of the outcome of such court proceeding.
7.2.2.
Rule R-7(b) is not adopted.
Instead, the parties stipulate that a contract exists between them and that
such contract is subject to arbitration as the exclusive remedy.
7.2.3.
Rule R-7(c) is not adopted.
Instead, the parties waive any objections to the jurisdiction of the arbitrator
or the arbitrability of any claims or counterclaims arising under this
Agreement.
7.2.4.
Rule R-10 is not adopted.
Instead, the parties agree that the locale fixed herein may not be changed
without the express written agreement of all parties.
7.2.5.
Rule 11(a). Rule 11(a) is
adopted except to the extent that such Rule permits the AAA to vary the number
of names submitted from the National Roster. The AAA must submit at least 5
names from the National Roster.
7.2.6.
Rule R-11(c) is not adopted.
7.2.7.
Rule R-15 is adopted except that
the parties agree that the AAA has no discretion to alter the number of
arbitrators except by express written agreement of the parties.
7.2.8.
Rule R-22 is adopted except to
the extent that such Rule permits the arbitrator to alter the locale of the
hearing. The arbitrator has no authority to alter the locale of the hearing
without the express written consent of the parties.
7.2.9.
The AAA shall have no power
whatsoever to alter the terms of this Agreement
7.2.10.
The arbitrator shall be chosen
from a panel of persons knowledgeable in commercial disputes relating to the
provision of, and coverage and payment for, medical services. The power and
office of the arbitrator shall arise wholly and solely from this Agreement, the
Commercial Rules and the Federal Arbitration Act, or the Texas Arbitration Act,
if it has been determined pursuant to Section 7.2 that the Federal Arbitration
Act does not apply.
7.2.11.
THE ARBITRATION SHALL BE
CONDUCTED IN AMARILLO, POTTER COUNTY, TEXAS. The AAA is without authority to
alter the locale of the arbitration without the express written consent of all
parties.
7.2.12.
The arbitrator shall deliver a
final award within sixty (60) days after the record of such arbitration is
declared to be closed, which shall be no longer than thirty (30) days following
an evidentiary hearing, if one is held, or the date of submission of the matter
to the arbitrator on briefs, if the parties agree in writing to waive an
evidentiary hearing.
7.2.13.
The award of the arbitrator so
rendered shall be final and binding, except to the extent that any arbitration
award may be modified or vacated pursuant to Texas law. The award so rendered
may be confirmed, modified or vacated only in a court of appropriate
jurisdiction in Amarillo, Potter County, Texas. After delivery of the award,
the arbitrator shall have no further jurisdiction or power except to correct
the award as permitted by Rule R-46 of the AAA Commercial Rules.
7.2.14.
This agreement shall be
interpreted and construed in accordance with the laws of the State of Texas.
In any litigation in connection with or to enforce this Agreement, the parties
irrevocably consent to and confer personal jurisdiction in the courts of the
State of Texas or the United States District Court for the Northern District of
Texas, Amarillo Division.
8.
Miscellaneous.
8.1.
This Agreement contains the entire
agreement of the parties relative to the services to be provided to SUBSCRIBER
and Covered Persons, and no representations, inducements, promises or
agreements, oral or otherwise, between the parties not embodied in this
Agreement will be of any force or effect.
8.2.
This Agreement specifically
supersedes any prior written or oral agreements between the parties relating to
the provisions of the services.
8.3.
This Agreement is binding upon, and
inures to the benefit of, and is enforceable by CARE TODAY, SUBSCRIBER and
their respective legal representatives, assigns and successors in interest,
subject to Paragraph 8.4 below.
8.4.
Neither party may assign this
Agreement without the prior written consent of the other party, provided that
this Agreement will be deemed assigned to, and will be binding upon, the
survivor in any merger or business combination involving CARE TODAY or the
purchaser of all or substantially all of the assets of CARE TODAY.
8.5.
Any amendments or changes in this
Agreement will be in writing and will not be effective until executed or signed
by both parties.
8.6.
CARE TODAY and SUBSCRIBER
acknowledge that they each have the full power and authority to execute,
deliver and perform this Agreement and to consummate the transactions
contemplated hereby.
Exhibit “A” – Standard Services
Evaluation and Management
(E/M) Services
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Radiology Procedures
|
Office/ Outpatient visit;
new; 10 minutes
|
X-ray eye for foreign body
|
Office/ Outpatient visit;
new; 20 minutes
|
X-ray exam of jaw; partial;
less than 4 views
|
Office/ Outpatient visit;
new; 30 minutes
|
X-Ray exam of facial bones;
less than 3 views
|
Office/ Outpatient visit;
new; 45 minutes
|
X-Ray exam of facial bones;
minimum 3 views
|
Office/ Outpatient visit;
new; 60 minutes
|
X-Ray exam of nasal bones;
complete
|
Office/ Outpatient visit;
est; 5 minutes
|
X-ray exam of skull; less
than 4 views
|
Office/ Outpatient visit;
est; 10 minutes
|
X-ray exam of skull;
complete; minimum 4 views
|
Office/ Outpatient visit;
est; 15 minutes
|
X-ray exam of jaw joints;
bilateral
|
Office/ Outpatient visit;
est 25 minutes
|
Chest x-ray; single view;
frontal
|
Office/ Outpatient visit;
est 40 minutes
|
Chest x-ray; two views;
frontal/lateral
|
|
Chest x-rays two views;
w/apical lordotic procedure
|
Surgery Procedures
|
Chest x-ray; two views;
w/oblique projections
|
Acne surgery of skin abscess
|
X-ray exam of ribs;
unilateral; two views
|
Incision and drainage of
skin abscess; simple
|
X-ray exam of ribs/chest;
minimum 3 views
|
Drainage of skin abscess;
complicated
|
X-ray exam of ribs;
bilateral: 3 views
|
Incision and removal of
foreign body; simple
|
X-ray exam of ribs/chest;
minimym 4 views
|
Puncture aspiration of
abscess, hematoma, bulla or cyst
|
X-ray exam of breastbone;
minimum 2 views
|
Debride skin; partial
thickness
|
X-ray exam of breastbone;
minimum 3 views
|
Benign hyperkeratotic
lesion; single
|
X-ray exam of spine;
anteroposterior & lateral
|
Benign hyperkeratotic
lesion; 2-4 lesions
|
X-ray exam of spine; single
view; specify level
|
Trim nondystrophic nails;
any number
|
X-ray exam of neck spine;
cervical; 2 or 3 views
|
Debride nails, 1-5
|
X-ray exam of trunk spine;
standing
|
Debride nails, 6 or more
|
X-ray exam of thoracic
spine; 2 views
|
Drain blood from under nail
|
X-ray exam of trunk spine; 2
views
|
Repair superficial wound(s);
2.5 cm or less
|
X-ray exam of trunk spine;
scoliosis study
|
Repair superficial wound(s);
2.6 to 7.5 cm
|
X-ray exam of lower spine; 2
or 3 views
|
Closure of split wound; w/
packing
|
X-ray exam of pelvis; 1 or 2
views
|
Layer closure of wound(s);
2.5 cm or less
|
X-ray exam of pelvis;
minimum 3 views
|
Layer closure of wound(s);
2.6 to 7.5 cm
|
X-ray exam sacroiliac
joints; less than 3 views
|
Layer closure of wound(s);
2.5 cm or less
|
X-ray exam of tailbone;
minimum 2 views
|
Layer closure wound of neck,
hand, feet; 2.6cm to 7.5cm
|
X-ray exam of collarbone;
complete
|
Repair of wound or lesion;
trunk; 1.1 cm to 2.5cm
|
X-ray exam of shoulder
blade; complete
|
Treatment of burn(s); w/o
anesthesia. Office; small
|
X-ray exam of shoulder; one
view
|
Treatment of rib fracture;
closed
|
X-ray exam of shoulder;
minimum 2 views
|
Treat elbow dislocation;
child; nursemaid elbow
|
X-ray exam of shoulders;
minimum 2 views
|
Treat finger dislocation;
w/o anesthesia
|
X-ray exam of humerus
|
Removal of foreign body,
foot; subcutaneous
|
X-ray exam of elbow; 2 views
|
Treat metarsal fracture; w/o
manipulation; each
|
X-ray exam, of elbow;
minimum 3 views
|
Treatment of toe fracture;
w/o manipuation
|
X-ray exam of forearm; 2
views
|
Apply long arm splint
|
X-ray exam of wrist; 2 views
|
Apply forearm splint; static
|
X-ray exam of wrist; minimum
3 views
|
Application of finger
splint; static
|
X-ray exam of hand; 2 views
|
Application long leg splint
|
X-ray exam of hand; minimum
3 views
|
Application lower leg splint
|
X-ray exam of finger(s);
minimum 2 views
|
Remove foreign body,
intranasal; office prodedure
|
X-ray exam of hip;
unilateral; one view
|
Venipuncture; under 3 yrs;
other vein
|
X-ray exam of hip; complete;
minimum 2 views
|
Venitpuncture; child over 3
yrs/ adult
|
X-ray exam of hips;
bilateral; minimum 2 views each
|
Collection of venous blood
by venipuncture
|
X-ray exam of pelvis &
hips; infant/child; minimum 2 views
|
Remove vaginal foreign body
|
X-ray exam of thigh; 2 views
|
Remove foreign body from
eye; external
|
X-ray exam of knee; 1 or 2
views
|
Remove foreign body from
eye; conjunctival embedded
|
X-ray exam of knee;
complete; 4 or more views
|
Remove impacted ear wax
|
X-ray exam of both knees;
standing anteroposterior
|
|
X-ray exam of lower leg; 2
views
|
Laboratory Procedures -
Single
|
X-ray exam of ankle; 2 views
|
Manual Urine Analysis
Reagent Strip U/A test
|
X-ray exam of ankle;
complete; minimum 3 views
|
Urine pregnancy test;
Pregnancy HCG Cassette
|
X-ray exam of foot; 2 views
|
Test feces for blood; by
peroxidase activity
|
X-ray exam of foot;
complete; minimum 3 views
|
Reagent strip; blood glucose
|
X-ray exam of heel minimum 2
views
|
Glycated hemoglobin test
|
X-ray exam of toe(s);
minimum 2 views
|
TB intradermal test
|
X-ray exam of abdomen;
anteroposterior view
|
StrepTest Rapid; Strep A
Dispstick Waived
|
X-ray exam of abdomen;
ap/oblique/cone views
|
Flourets 1 Mg OPH Ophthalmic
Test
|
X-ray exam of abdomen;
include decubitus/ erect views
|
H Pylori Test
|
X-ray exam series; abdomen;
complete
|
Hemoccult Sensa Single Slide
Test
|
|
|
|
Laboratory Procedures -
Bundled
|
Medicine - Cardiography
|
Lipid Panel
|
Electrocardiogram; complete
with at least 12 leads
|
Lipid Panel + Glucose Test
|
Electrocardiogram; w/tracing
only
|
Basic Metabolic Panel
|
Rhythm ECG; w/ report, 1-3
leads
|
Comprehensive Metabolic
Panel
|
Rhythm ECG; tracing only
|
Elecrolyte Panel
|
Special Supplies
|
Renal Function Panel
|
Eye Tray Supplies
|
Hepatic Function Panel
|
Suture Tray Supplies
|
Kidney Check Panel
|
|
Liver Panel
|
|
Metlyte 8-Panel
|
|
General Chemistry 6-Panel
|
|
General Chemistry 13-Panel
|
|
|
|
Medicine - Pulmonary
|
|
Spirometry (Breathing
capacity test)
|
|
Patient recorded spirometry;
w/ recording
|
|
Patient recorded spirometry;
review/interpret
|
|
Evaluation of wheezing;
before/after bronchodilator
|
|
Evaluation of wheezing; w/
subsequent spirometrics
|
|
Vital capacity test
|
|
Respiratory flow volume loop
|
|
Nebulizer treatment
(inhalation treatment, acute)
|
|
Noninvasive ear or pulse
oximetry for oxygen saturation
|
|
|
|