Letter of Agreement for Membership
Dear partner in health,
I am delighted that you have chosen to participate in Community Supported Family Medicine’s (CSFM’s) Membership Program. The Membership Program provides participants with comprehensive primary care services for a simple monthly price.
What Is Included: As a CSFM member you will receive almost unlimited and appropriate office-based primary health care services provided by me, Dr. Robin Dickinson MD, at no additional charge for my services up to 99 encounters per month. This includes well/preventive visits, sick visits, chronic disease management, lifestyle recommendations and monitoring, certain urgent care (that does not require imaging or other supplies I don’t have available), follow-up visits, basic wound care, suturing that does not require a surgeon, basic skin biopsies (pathology billed separately), spirometry with interpretation, as well as appropriate phone consultations/visits and web portal messaging (secure email). Every effort is made to accommodate urgent medical needs with same-day or next-day availability but this is not guaranteed. Wellness or preventive visits, follow-up visits, medication refills, and non-urgent matters are not expected to be seen during same day/next day visits.
How to Contact Me: One of the benefits to becoming a member at CSFM is the direct relationship you have with me. Since there are no staff complicating our interactions, you will need to learn the appropriate way to contact me in case of various medical needs.
|Non-urgent line, call main number and follow prompts||
|Urgent line, call main number and follow prompts||
When Physician is Not Available: On the occasion that I am out of town, I will generally arrange for another health care provider to see you under the terms of your membership unless I feel it would be more appropriate for you to wait for my return or to be seen at an urgent care or ER. I do close my office for 2-3 weeks a year during which I am generally available by phone or have another physician answering calls for me but this is not guaranteed. During this time, there are numerous urgent cares and ERs able to see you for medical issues that cannot wait.
Communication Methods: Because of the direct nature of my practice, you are able to communicate with me via secure portal messaging, cell phone, facsimile, video chat, instant messaging, and e-mail. These communication methods cannot be guaranteed to be secure or confidential. If you choose to disclose private information (including protected health information or PHI) on any of these communication methods, then you are giving me permission to continue to use that communication method for all protected health information unless you revoke that permission.
What is Not Included: Membership benefits do not include any services provided by other health care providers, institutions, or organizations. Specialists, hospital and emergency room visits, imaging, laboratory testing, vaccinations, medications, and other care not listed here are not included in your membership. You, the member, are responsible for the charges for all the services, supplies, medication, and equipment that are not included in the cost of membership. If you have insurance, these outside services may bill your insurance, but you must generally arrange this with them yourself. When I have a discounted rate with a lab or other facility, that discounted rate will be made available to you but this is contingent on the agreement with that lab or other facility, which is outside my control.
Not Insurance: The membership program is not health insurance and CSFM will not directly bill insurance for any of the care received. I do not participate with any private health insurance company and you should not expect to be reimbursed by your health insurance company or have any costs incurred here go towards your insurance deductible. While the majority of primary care services that can be provided in an outpatient office are included in the membership, additional costs may be incurred for medications from the pharmacy, vaccinations, laboratory, medical imaging, surgery, specialist care, emergency department visits and hospitalization. For this reason, patients are generally best served by combining a membership with an ACA compliant insurance policy to cover other services.
Government Health Programs: Due to regulatory restrictions, membership with CSFM may not be available to those who are eligible for or enrolled in Medicare, Medicaid or other government health programs.
Billing Details: Standard membership is $40 a month for each of the first two members of a household. Each subsequent household member is eligible to pay a $15 discounted membership rate. The registration fee is $80 for the first family member to see me. The rest of the family will simply pay their first month’s membership rate.
Your benefits of membership begin at the time of your first appointment with me when your first payment is made. Membership is paid in arrears and subsequent months are due by the last day of that month unless other arrangements have been made and is payable by automatic debit from your debit or credit card account. In addition to medical costs described above, you agree to pay CSFM’s established charges related to house calls (for special circumstances only), returned checks, copies of medical records provided to the patient, and other administrative/compensatory fees. These fees are available upon request and subject to change without notice.
Members who miss payment for two (2) consecutive months are assumed to be notifying me that they are terminating membership in the practice.
In order to remain financially viable, I may need to change (add or discontinue) services or change my fee schedule at any time. You will receive written notice at least sixty (60) days prior to any changes taking effect. If it is necessary for you to pause your membership due to an absence for more than two (2) months, please speak to me right away to make appropriate arrangements.
Term of Membership and Leaving CSFM: Membership in CSFM is designed and intended to be continuous, though you may terminate your membership at any time. Your membership will automatically renew every month when your membership is paid. If you terminate your membership, you will have to wait 12 months to reinstate your membership (and go to the bottom of the waiting list, if applicable) and pay a $200 reinstatement fee. CSFM will reimburse you any fees collected in advance for the month(s) following the termination of membership. You may request termination of membership agreement, in writing, at any time.
If you choose to terminate your membership due to a grievance, you agree to give me an opportunity to make it right, prior to terminating or taking other action.
CSFM may exclude or terminate any individual or household from participation in the Membership Program just as you have the right to choose your physician. This is extremely rare but the reasons that any medical office may exclude a patient from their practice include (but are not limited to): if you do not pay fees when they are due; you commit fraud; you are abusive, disruptive, or present an emotional or physical danger to the physician, other building occupants, or patients; or the practice closes. You will receive written notification if your membership is terminated.
Once your membership is terminated for any reason, you will not be eligible for any medical services, including medication refills.
Non-discrimination: CSFM is particularly suited to care for people who are looking for a safe place to receive medical care in line with their values and current life situation. Under no circumstances will I discriminate against you, or terminate your membership agreement, on the basis of sex, race, color, religion, ancestry, national origin, disability, medical condition, genetic information, marital status, sexual orientation, citizenship, primary language, immigration status, or any other protected status. For your safety, I do reserve the right to accept or decline patients based on my capability to appropriately manage your primary care needs given the resources and staffing available in my practice.
Privacy: I abide by all patient privacy rules and regulation mandated by the Health Insurance Portability and Accountability Act (HIPAA).
Final statements: This is a private letter of agreement between CSFM (Robin Dickinson, MD) and you/your family. This letter (signed by each responsible party) and attached list of household members signed by the household’s financially responsible person constitutes the full terms of your membership. This letter is subject to the laws of Colorado and all official disputes about this letter will be settled by arbitration services chosen by CSFM with costs shared equally between us.
I look forward to many years of working together towards your better health!
Robin Dickinson MD