Patient Agreement

This agreement (“Agreement”) is entered into between One to One Concierge Health, L.L.C., a Florida professional corporation located in Tampa, Florida, 33614, owned by Suzzette Alio Llado MD and Barbara M Blasini Rodriguez MD (collectively referred to as “Physicians” or “Physician”), acting as agents of One to One Concierge Health, and you, the patient (“Patient” or “you”):

Patient Printed Name: __________________________________________________

Background

Suzzette Alio Llado MD and Barbara M Blasini Rodriguez MD specialize in family medicine and provide care on behalf of One to One Concierge Health at the above-mentioned address. In exchange for specific fees paid by the Patient, One to One Concierge Health, through its medical physicians and other providers, agrees to provide the Patient with the Services described in this Agreement, subject to the terms and conditions set forth herein.

Definitions

  1. Patient: A patient is defined as an individual for whom the Physician or other provider will provide Services, and who is a signatory or listed on the documents attached as Appendix 1, incorporated by reference into this agreement.
  2. Services: The term “Services” refers to a package of medical and non-medical services, as well as certain amenities, collectively provided by One to One Concierge Health and described in Appendix 1.
  3. Term; Termination:
    a. This Agreement will commence on the date signed by the parties and continue until the completion of the telemedia or home visit services.
    b. Either the Patient or One to One Concierge Health has the right to terminate the Agreement by providing prior written notice to the other party.
  4. Fees: In consideration for the services described herein, the Patient agrees to pay One to One Concierge Health the amount specified in Appendix 1. The fee is payable upon execution of this Agreement and covers the services provided to the Patient during the term of this Agreement.
  5. Insurance Coverage: One to One Concierge Health and the Physician do not participate in any health insurance or governmental benefit plans for reimbursement of healthcare fees. The Patient retains full responsibility for determining whether the fees paid under this Agreement are covered by their health insurance or third-party payment plans. If the Patient is eligible for Medicare or becomes eligible during the term of this Agreement, additional requirements outlined in Appendix 2 apply.
  6. Medical Insurance: The Patient acknowledges that this Agreement is not an insurance plan and does not replace health insurance coverage. It is recommended that the Patient maintain comprehensive health insurance coverage for general healthcare, major medical, and hospitalization costs.
  7. Physician Discretion: The Physician and One to One Concierge Health have sole discretion in providing services and prescriptions. The exercise of such discretion does not entitle the Patient to a refund of any fees paid. However, both the Patient and One to One Concierge Health may terminate the Agreement upon providing sufficient prior written notice.
  8. Communication: The Patient acknowledges that communications with the Physician using email, Atlas med, video chat, instant messaging, and cell phone may not be secure or confidential. The Patient waives the Physician’s obligation to guarantee the confidentiality of such communication methods. The Patient’s email address and cell phone number provided in this Agreement authorize communication regarding the Patient’s protected health information (PHI) within the limits defined by the Health Insurance Portability and Accountability Act (HIPAA). The Patient understands the limitations and responsibilities associated with email and text messaging communication.
  9. Change of Law: If there are changes in laws, regulations, or rules that substantially affect the Agreement or either party’s rights and obligations, the parties may initiate negotiations to modify the Agreement. If an agreement cannot be reached within 45 days, either party may terminate the Agreement.
  10. Severability: If any provision of this Agreement is deemed legally invalid or unenforceable in any applicable jurisdiction, the validity of the remaining provisions shall not be affected. The provision in question shall be modified to the minimum extent necessary to comply with applicable law, and in its modified form, it shall be enforceable.
  11. Reimbursement for Services Rendered: If this Agreement is invalidated for any reason, resulting in the refund of fees paid by the Patient, the Patient agrees to compensate One to One Concierge Health for the reasonable value of the Services actually provided during the period for which the refunded fees were paid.
  12. Amendment: No amendment to this Agreement shall be binding unless it is made in writing and signed by all parties. However, One to One Concierge Health reserves the right to unilaterally amend the Agreement, with 30 days’ advance written notice, to comply with federal, state, or local laws or regulations. Such changes are incorporated by reference and become effective as of the date established by One to One Concierge Health. The Patient must initial any such change.
  13. Assignment and Relationship of Parties: The Patient acknowledges that this Agreement may not be assigned or transferred, but One to One Concierge Health may do so without notice or consent. The Physician, in performing their duties under this Agreement, is considered an independent contractor, as defined by the guidelines of the United States Internal Revenue Service and/or the United States Department of Labor. The Physician retains exclusive control over their work and the manner in which it is performed.
  14. Legal Significance: The Patient recognizes that this Agreement is a legally binding document that establishes rights and responsibilities. The Patient acknowledges having had a reasonable opportunity to seek legal advice regarding the Agreement and either chose not to do so or is satisfied with its terms and conditions.
  15. Miscellaneous: This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party responsible for drafting it. Captions in this Agreement are provided for convenience only and do not limit, broaden, or qualify the text.
  16. Entire Agreement: This Agreement represents the entire agreement between the parties, superseding all prior oral and written understandings and agreements pertaining to the subject matter herein.
  17. Jurisdiction: This Agreement shall be governed and construed in accordance with the laws of the State of Florida. Any disputes arising from this Agreement shall be settled in the appropriate court of jurisdiction for One to One Concierge Health’s address in Tampa, Florida.
  18. Service: All written notices are considered served when sent by first-class U.S. mail to the addresses of the respective parties listed in this Agreement.

Both parties have signed duplicate counterparts of this Agreement on the date first written above.

One to One Concierge Health, LLC

By:

Printed Name:

Patient Address:

Patient Email Address:

Patient Cell Phone Number:

Appendix 1

Medical Services: The term “Medical Services” refers to the medical services provided by the Physician or other authorized providers under the laws of the State of Florida. These services include, but are not limited to, medical visits for acute illnesses, certain diagnostic tests, medication injections, oral treatments, and specified procedures. Additional services may be added by Physician on an ongoing basis
 
The Physician may from time to time, due to vacations, sick days, and other similar situations,
may not be available to provide the services referred to above in this paragraph.

One to One Concierge Health offers a range of non-medical services to enhance the patient experience:

  1. Access to Physician: You will have direct access to our physician via cellphone, texting, and video chat for urgent matters. We will provide you with a special cell phone number to reach the physician or her representative promptly.
  2. E-mail Communication: You will be given the physician’s email address for non-urgent communications. Our physician or staff members will respond to these communications promptly. However, please note that email and the internet should not be used for medical emergencies. In such situations, please call 911 or the nearest emergency medical assistance provider for immediate help.
  3. Minimal Wait Appointments: We strive to ensure that you are seen by the physician without significant wait times for both tele-visit and home/office-visit appointments. If there is a minimal wait time, we will contact you in advance and provide an estimate of the projected wait time.
  4. Same Day/Next Day Appointments: If you contact the physician prior to noon on a normal business day to schedule an appointment, we will make every reasonable effort to accommodate a same-day appointment. For inquiries received after noon, we will schedule your appointment with the physician on the following business day. However, we will always strive to schedule your appointment on the same day as the request.
  5. Telephone Consultations: When appropriate, you have the option to schedule telephonic consultations with the physician at a time convenient for both parties.
  6. Home or Office Visits: At your request, the physician will make every reasonable effort to visit you at your home or office when deemed reasonably necessary and appropriate.
  7. Visitors and Family Members: Medical services provided to your family members or visitors will be charged on a fee-for-service basis.
  8. Referrals to Specialists: If necessary, One to One Concierge Health may refer you to specialists for additional care. Please note that fees paid under this Agreement do not cover specialists’ fees or fees charged by other medical professionals. While our primary care physician will do their best to manage your condition within their scope of practice, there are situations where specialist care is medically necessary.
  9. Emergency Room Referrals: If the physician determines that you require further evaluation or a higher level of clinical treatment, you may be referred to the Emergency Department (ED) for appropriate care. Please be aware that One to One Concierge Health is not responsible for returning the fee-for-service payment, and you will be charged the complete amount for our services. Additionally, One to One Concierge Health is not responsible for any charges incurred at the ER.

Wholesale Medications: You may have access to prescription and over-the-counter medications through our wholesale medication partner, providing significant savings.

Patient and One to One Concierge Health agree not to record any audio or visual content without the written permission of both parties.

By signing below, you acknowledge that you have read and understood the above services provided by One to One Concierge Health.

One to One Concierge Health, LLC

Patient Initials:

Patient Signature: