Membership Agreement

This is the letter you will sign when you register on the portal as a new patient:
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 comprehensive primary care services for a simple monthly price.

Not Insurance: The membership program is not comprehensive health insurance. I supply only specific primary care services and your membership at CSFM makes those services I provide available to you for a single low monthly cost. CSFM will not bill insurance for any of the care received and if you attempt to obtain insurance reimbursement, that can get us both in trouble. Care received at CSFM does not go towards your insurance deductible. You still need to purchase high deductible health insurance to cover any catastrophic medical expenses you may incur outside of this practice and to meet the requirements of the Affordable Care Act and avoid paying a penalty.

What Is Included and How It Works: As a CSFM member you will receive appropriate office-based primary health care services provided by me, Dr. Robin Dickinson, 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, spirometry with interpretation, as well as appropriate phone consultations/visits and web portal messaging (secure email).

Because I count on members for my support I am able to offer phone visits to members whenever medically appropriate to allow you the convenience of staying home or avoiding an extra stop in your busy day. Conventional medical billing makes it difficult for health care providers to make ends meet without physically seeing a patient so many doctors will require you to come in to discuss lab results or other health concerns for which a physical examination isn’t medically indicated. Of course, it’s good practice (and medically indicated) to let your doctor see you in person in certain circumstances so I do ask that members come to the office for visits whenever possible and require office visits when medically appropriate.

I provide same-day or next-day availability to members in the event of acute illness or urgent medical need Monday through Thursday except holidays and Friday through Sunday and holidays, if appropriate. In a life-threatening emergency, call 911!

For urgent medical issues please reach me one of the following ways:

During regular business hours: If you have an issue that cannot wait until the end of the business day, including a request for a same-day appointment, please call the office number and press 3 to leave me a message and page me so that I call you back immediately. Please know that by paging me during business hours, you are likely interrupting another patient’s appointment, but do not hesitate to do so if your matter is urgent. For non-urgent matters, press 1 to leave a message and I will return calls within 24 hours or the next business day.

After Hours (evenings, weekends and holidays): Please call the regular office number and press 3 to page me. I should return your call within 30 minutes. If the call is not returned, please try again in case phone coverage was interrupted. After telephone discussion and agreement by me that your situation requires same-day attention, I will help you over the phone or arrange to see you in the office, or refer you to another facility as appropriate. Wellness or preventive visits, follow-up visits, medication refills, and non-urgent matters are not guaranteed same day/next day visits.

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 arrange this with them yourself.

Billing details: Your benefits of membership begin on the first day of the month for which your membership fee is paid. Subsequent months are due by the end of the month for which you are paying. 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.

Membership fees are due by the end of each month (unless other arrangements have been made) and apply to the entirety of that month. Members who miss payment for more than two (2) consecutive months will be terminated and will have to wait 6 months to reinstate their membership(s) or pay a $200 reinstatement fee.

I may choose 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.

Leaving CSFM: Membership in CSFM is designed and intended to be continuous, though you may terminate your membership at any time. If you terminate your membership, you will have to wait 6 months to reinstate your membership or pay a $200 reinstatement fee. CSFM will reimburse you any fees collected in advance for the month(s) following the termination of membership. Please request the termination in writing and with a 72 hour notice before your next payment pulls. CSFM does not offer prorated refunds for partial months.

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. CSFM may exclude or terminate any individual or household from participation in the Membership Program.



Robin Dickinson MD