Terms and Conditions

Grossman Concierge Services, A Dental Professional Corporation

Patient Membership Agreement

email: Info@drjaydds.com

 

This Membership Agreement (the “Agreement”) sets forth the terms and conditions with respect to the professional services (the “Professional Services”) provided by Grossman Concierge Services, A Dental Professional Corporation (“Group”), also known as Doctors Who Care, with respect to the Member identified above.

 

 

TERMS AND CONDITIONS

 

1.  Member Responsibilities:  I acknowledge and understand that I am voluntarily becoming a Member of Grossman Concierge Services, A Dental Professional Corporation ”) and that this Agreement is non-transferable and will govern my relationship with any professional affiliated with the Group whom I see for care (“Group Professionals”).  I acknowledge and understand that this Agreement does not provide health insurance coverage nor is it a contract of insurance and that it provides only access to the particular services specifically described in this Agreement, subject to Group policies.  I acknowledge and understand that I am responsible for any charges incurred for services performed outside of the Group, including but not limited to any other healthcare services, and that the Group does not bill insurance carriers for any services provided by its affiliated professionals.  In order to receive the best possible care, I agree to be actively involved in my care decisions and to disclose all relevant information to the doctors I seek care with to help me achieve my health goals. I also agree to inform doctors of any healthcare services I receive from other healthcare providers.  I agree to maintain insurance coverage to obtain hospital or catastrophic services if needed.  I acknowledge that, in an emergency, I should call 911 immediately before Group and seek any needed emergency care without waiting for Group’s response.

 

2.  Professional Responsibilities:  I understand that the Group will be providing me with: 

• management and coordination of my care, including access to a professional and appointments with sub-specialist professionals in certain sub-specialties;

• to the extent reasonably possible, same-day or next day appointments with a Group Professional during regular business hours (excluding holidays);

• reasonable efforts to minimize waiting time during office appointments;

• reasonable amounts of time with professionals to allow for management of your healthcare problems, discussion of preventive care, and answering your questions;

• reasonably prompt response by telephone, email, and text; and

• access to member portal with all the doctors that participate with private text messaging to each provider

 

There may be infrequent times in which Group Professionals are delayed, and it will become necessary for the Group to substitute a different professional for my care, in which case there may be an unavoidable delay.  I understand that the Group only provides consultations with sub-specialists in certain subspecialties.  I understand that I am responsible for the costs of diagnostic or laboratory tests ordered (even when ordered by Group Professionals), or any fees associated with healthcare professionals, facilities, or services other than Group Professionals during a consultation with me.  In such instances, Group Professionals will personally discuss my case with any outside health professionals involved in my care, but the other professionals, facilities, and services will bill me according to whatever agreement exists between them and my insurance.  I agree to maintain current insurance coverage to obtain services detailed in paragraph 2 above that are not covered by this Agreement.  I understand that this Agreement cannot be entered into during a time when I require or will in the foreseeable future require emergency care services or urgent care services.

 

3.  Member Rights:  I understand that I have the right to choose my provider and to change providers at any time, for any reason. I understand that all reasonable efforts will be made to accommodate my request, but only if my new professional is open to new Members.  I understand that I have the right to receive accurate and understandable information about the Group’s services and professionals.  If I speak a language different from my counselor, have a physical or mental disability or do not understand something, I understand that the Group will make its best effort to provide assistance so I can make informed health care decisions. If I require interpreter services beyond what can be provided by the Group, professional interpreters may be provided at an additional cost to me.  I understand that I have the right to respectful and nondiscriminatory care from the Group representatives and providers.  I also understand that I am responsible for communicating clearly and respectfully with the Group representatives and my provider(s).  Should I become dissatisfied with my care by any provider, I agree to notify the Group immediately so my concerns may be addressed in a timely manner.  I understand that I have the right to speak in confidence with my provider(s) and to have my health care information protected.

 

4.  Membership Fee:  I understand and agree that I must pay the annual fee (“Concierge Access Fee”) of One Thousand Nine Hundred Ninety-Five Dollars ($1,995.00) as a single individual, or Three Thousand Five Hundred ($3,500) as a couple, or Seven Thousand Five Hundred ($7,500) for a family, to maintain my status as a Member, payable to Group.

 

5.  No Fixed Charge:  I understand that this Agreement is not a sale of insurance and is not the provision of fixed services required to be licensed by the Knox-Keene Act.  I understand that the Group Professional(s) will invoice me annually for membership and my individual doctors will invoice the insurance carrier for the Professional Services rendered to me. 

 

6.  Complaints:  I understand that I have the right to a fair, prompt and objective review of any complaint I have against any provider(s) with whom Group connects me, or any other staff, including complaints about wait times, operating hours, conduct of personnel, business practices, and adequacy of services and facilities.  I agree to first bring any complaints to the attention of Group staff and to participate in the Group complaint and grievance process.

 

7. Health Information:  I acknowledge and understand that the Group maintains a record of my health information, and protects the privacy of my health information as per the terms of the Notice of Privacy Practices. I understand and acknowledge that this policy is available for my review at any time on the Group website.  I understand that the Group will not disclose my information without my authorization or without a legal obligation to do so. I also understand that I have the right to review and receive a copy of my personal medical record and may request that my health care provider(s) amend my record if I feel it is inaccurate or incomplete.

8.  Termination:

            8.1 Termination by Member:  I acknowledge and understand that I may terminate this Agreement at any time and for any reason, or for no reason, by sending a written Service Cancellation Form to Group at the following address:  11980 San Vicente Blvd., Ste 507, Los Angeles, CA 90049.  The yearly fee is non-refundable, and once the termination letter is received, it will expire on the anniversary date, at which time the Group is no longer responsible for my care.  Termination of the membership plan is separate from any fees incurred at the individual doctor’s offices.

            8.2 Termination by the Group:  I acknowledge and understand that the Group reserves the right to terminate this Agreement and discharge me as a Member at any time with or without cause, including failure to pay bills and refusal to cooperate.  I will be provided with written notice of termination thirty (30) days in advance of the effective date by certified mail or overnight delivery service.  The Group will not terminate this Membership Agreement solely on the basis of my health status. 

9.  Financial Responsibility:  I hereby acknowledge that payment in full for services rendered (or for any damages or claims under paragraph 2 above) is due upon receipt of the invoice. The membership fee is due in full and is non-refundable and valid for one year from the date payment is received. Furthermore, services may be discontinued on either a temporary or permanent basis if the balance is not paid as provided for herein.  Responsible Party understands and agrees that he/she is accepting financial responsibility for this debt and will be required to pay for all services provided by the Group if the Member does not pay.  The Group may collect this debt from Responsible Party without first trying to collect from Member.  Furthermore, Member and Responsible Party agree to jointly and severally pay any and all costs and expenses incurred by the Group in the collection of this debt, including but not limited to court costs, attorneys’ fees, and costs of appeal.

10. Changes in Prices, Terms, and Conditions:  The Group reserves the right to amend the prices, terms, and conditions of this Agreement upon thirty (30) days prior notice to Member/Financially Responsible Party.  Subject to applicable laws, rules, and regulations, this Agreement represents the entire agreement of the parties regarding the Professional Services provided by the Group.  Either party may make no other amendments or modifications without notice to and acceptance in writing by both parties. The fee will not change during the year a membership contract is in force. Changing in pricing may only take place at renewals.

 

11.  Renewal:  This Agreement shall become effective on the first date of Professional Services and shall continue in full force and effect unless and until terminated by Member, Financially Responsible Party, or the Group. 

 

12.  Applicable Law:  This Agreement shall be governed by and construed under and in accordance with the laws of the State of California as an agreement made and wholly to be performed therein.  The undersigned hereby consents to the jurisdiction of the State Courts of California or the Federal Courts located therein and agrees that the venue of said courts is proper. In the event of any dispute pertaining to this Agreement, the prevailing party shall be entitled to its reasonable attorneys’ fees and costs.

 

13.  Force Majeure:  The Group shall not be liable for any injury, damage, claim, loss, or failure in performance under this Agreement resulting, directly or indirectly, from activities beyond Group’s control, including without limitation acts of God, accidents, fires, explosions, earthquakes, floods, failure of transportation, equipment, or supplies, vandalism, strikes or other causes beyond the Group’s control.

14.  Medicare Beneficiaries Only:  I acknowledge and understand that if I am enrolled in Medicare, I will receive a copy of the Medicare Beneficiary Private Agreement for review and signature before my first appointment with any Group Professional. (The Medicare Beneficiary Private Agreement does not prevent me from receiving current or future Medicare benefits; rather, it states that neither I nor my health care provider(s) will seek reimbursement from Medicare for the Professional Services I receive.)  I understand and acknowledge that some Group Professionals are not Medicare providers, meaning that neither they nor I am permitted to bill Medicare for the services they provide, and any secondary insurance will also not reimburse me for any services these Group Professionals provide.  I understand and agree not to submit a claim to Medicare or to ask a Group Professional to submit a claim to Medicare for services provided to me.  Neither Medicare nor secondary insurance will pay for any services provided by these Group Professionals, despite the fact that some services might have been covered by Medicare if the Group Professional was a Medicare provider. I have the right to obtain Medicare-covered services from a practitioner who is contracted with Medicare, and I am not compelled to enter into private agreements that apply to other Medicare-covered services furnished by other professionals or practitioners who have not opted-out. 

15.  Private Insurance Only:  I understand and acknowledge that some Group Professionals are not contracted and do not bill insurance, while others are contracted and will bill insurance.  I will abide by the directions of each Group Professional who cares for me with respect to the billing of private insurance and handling of private insurance claims, and will complete any forms reasonably requested by Group Professionals.

 

By checking the box upon signing up for the site, I agree to become a Group Member and I agree to the terms outlined in this Membership Agreement.

 

The undersigned certifies that he or she has read, understands, and agrees to the above terms and that he or she is duly authorized by the Member and/or the Responsible Party to execute the above and accept its terms.