PREMIER PLAN

Wellness Plan

Downloadable

agreementS

This Membership Agreement specifies the terms and conditions under which you, the undersigned member(s), will participate in the Concierge Wellness Program (the Program) of Andrew Lenhardt, M.D. (Dr. Lenhardt).

 

Dr. Lenhardt provides internal, family and holistic medicine medical services to patients.  You desire to receive, for a fee, certain non-medical services (the Services) as part of the Program from Dr. Lenhardt through this Membership Agreement. This Membership Agreement sets forth the terms and conditions of your participation in the Program, including the terms and conditions on which the Services will be provided to you. You and Dr. Lenhardt therefore agree as follows:

 

The Services Include the Following:

 

Same Day/Next Day Appointments with Dr. Lenhardt: You acknowledge that while providers often schedule same or next day appointments if there is a medical necessity for such a timeframe, the appointment is not always with the patient’s provider. Under this Membership Agreement, your appointment will be with Dr. Lenhardt (or, in the event of Dr. Lenhardt’ s absence due to illness, vacation or conference attendance, with his covering physician, Dr. Frank Harte or another provider at Well Life), and Dr. Lenhardt will make all reasonable efforts to see you the same day or the next day without regard to medical necessity.

 

24/7 Availability and Access: For those in the Premier Plan, you will have direct telephone access to Dr. Lenhardt 24 hours per day, 7 days per week through Dr. Lenhardt’s personal telephone number. If Dr. Lenhardt is unavailable due to vacation, illness or conference attendance, you will be given the direct telephone number a covering physician. You acknowledge that while it is customary for providers to have a 24-hour answering service, calls after hours are not necessarily with the patient’s provider. Pursuant to this Membership Agreement, those in the Premier Plan will have 24/7 access to Dr. Lenhardt.

 

You will also have direct email access to Dr. Lenhardt.  For those in the Premier Plan, Dr. Lenhardt will address those emails outside of normal business hours. If you wish to send secure e-mail communications to, and receive secure e-mail communication responses from, Dr. Lenhardt, and/or his employees, agents, co-workers or representatives, you must utilize the electronic medical record’s electronic communication system for which you will be given instructions. You should be aware that unlike the secure message service provided through the electronic medical record, traditional e-mail is not a secure method for sending or receiving potentially sensitive personal health information. You also acknowledge and understand that e-mail in any form is not a good method for urgent or time-sensitive communications. In the event a communication is time-sensitive, you must communicate with Dr. Lenhardt or the staff at Well Life by telephone or in person. You acknowledge and understand that, at the discretion of Dr. Lenhardt, or Well Life, your e-mail may become part of your medical record.

 

 

Membership Fees: Your Membership Fee and payment structure is described in Exhibit A attached to this Membership Agreement.

 

Medical Services/Exclusions from Program: In addition to the Services outlined above which you will receive as part of the Program, Dr. Lenhardt will provide general internal, family and/or holistic medicine services to you as a regular patient. Except for the Services that you receive as part of the Program, you and/or your insurer (whether commercial, Medicare or other third-party payor) will be financially responsible for paying for all medical services received by you from Dr. Lenhardt or the staff at Well Life. This means that while access to a same or next-day appointment is included in the Services that you receive as part of the Program, you or your insurer/Medicare will be responsible for the cost of the medical care provided in that appointment.

 

For those in the Premier Plan, the annual wellness evaluation will include additional testing not generally covered as part of annual physicals. For those over 50-years old, as part of the annual wellness evaluation, the member will get a urine analysis, an EKG, and a consultation with a nutritionist. They will also get a CT coronary plaque scan every two years. After each annual wellness visit, an individualized plan will be written up and provided that includes goals and priorities for the next year. The wellness evaluation will not include any item or service that is covered by your health insurance or Medicare, such as the “Welcome to Medicare Visit,” which shall be billed to your insurance company or Medicare, except for copays, deductibles or coinsurance which will be your responsibility.

 

Co-Payments/Other Out of Pocket Costs: Your payment of the Membership Fee will not affect the co-payments, co-insurance or deductibles that you are required to pay pursuant to the terms of your insurance coverage/Medicare. You will continue to be financially responsible for any co-payments, co-insurance or deductible amounts required by your insurer/Medicare for those services outside the Services that you receive as part of the Program.

 

Term and Termination: This Membership Agreement has an initial one (1) year term beginning on the date set forth on Exhibit A, and, unless and until terminated as set forth below, shall automatically renew for additional one (1) year terms.

 

You or Dr. Lenhardt may terminate this Agreement at any time upon 30 days’ written notice. If you or Dr. Lenhardt terminate this Agreement for any reason, you will be entitled to a prorated refund for any fees paid in full in advance. (Members can otherwise choose to pay in monthly installments if so desired and, under this payment arrangement, any monthly fees already paid will not be refunded.)

 

Vacations/Absences: All of your office visits will be with Andrew Lenhardt, MD, except when he is away on vacation, ill or attending a conference. For those times, he will be covered by Frank Harte, MD, and other appropriately qualified medical staff from Well Life.

 

Entire Agreement: The undersigned agrees to the terms of this Agreement, all of which expressed herein. There are no promises or representations between you and Dr. Lenhardt except as set forth herein.

 

Notices: Any communication required or permitted to be sent under this Agreement shall be in writing and sent via U.S. mail to the addresses set forth in Exhibit A. Any change in address shall be communicated in accordance with the provisions of this section.

 

Billing: Membership fees are charged annually or monthly as elected by the Member and reflected on Exhibit A and must be paid within thirty (30) days.  Monthly billing will start a month prior to the date each patient becomes an official patient under Dr. Lenhardt, e.g. for services that start March 1, 2017, the first payment will be due February 1, 2017. The monthly fee will continue to be billed a month in advance until the agreement is nullified either by the member or by Dr. Lenhardt. Copayments, deductibles and coinsurance shall be paid upon receipt of an invoice from Well Life and/or Dr. Lenhardt. Failure to keep up with annual or monthly payments for any and all portions of the Agreement may result in termination of this Agreement following written notice from Dr. Lenhardt.

 

Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the Commonwealth of Massachusetts without regard to Massachusetts’ choice of law provisions.

 

 

 

 

________________________________________              ___________

Andrew Lenhardt, M.D.                                               Date

 

 

 

________________________________________              ___________

Member Name:                                                              Date

 

 

________________________________________              ___________

Member Name:                                                              Date

 

 

Exhibit A

 

 

Effective Date: ______________

 

 

Check applicable Membership Fee:

 

 

________$200 per month for individuals in the Premier Plan

 

 

Check applicable payment structure:

 

_______ Annual in Full

 

_______ Monthly (12 equal installments)

 

 

Credit Card Number ______________________  Exp Date _________ CVV _____

 

Name on Credit Card __________________________________________

 

 

Name(s) of Member(s)                              Address for Member(s):

 

 

_______________________                       _________________________

 

 

_______________________                       _________________________

 

 

_______________________                       _________________________

This Membership Agreement specifies the terms and conditions under which you, the undersigned member(s), will participate in the Concierge Wellness Program (the Program) of Andrew Lenhardt, M.D. (Dr. Lenhardt).

 

Dr. Lenhardt provides internal, family and holistic medicine medical services to patients. You desire to receive, for a fee, certain non-medical services (the Services) as part of the Program from Dr. Lenhardt through this Membership Agreement. This Membership Agreement sets forth the terms and conditions of your participation in the Program, including the terms and conditions on which the Services will be provided to you.  You and Dr. Lenhardt therefore agree as follows:

 

The Services Include the Following:

 

Same Day/Next Day Appointments with Dr. Lenhardt: You acknowledge that while providers often schedule same or next day appointments if there is a medical necessity for such a timeframe, the appointment is not always with the patient’s provider. Under this Membership Agreement, your appointment will be with Dr. Lenhardt (or, in the event of Dr. Lenhardt’ s absence due to illness, vacation or conference attendance, with his covering physician, Dr. Frank Harte or another provider at Well Life), and Dr. Lenhardt will make all reasonable efforts to see you the same day or the next day without regard to medical necessity.

 

24/7 Availability and Access: For those in the Wellness Plan, any medical issues during regular office hours will be covered by Dr. Lenhardt or his private nurse. His private nurse will only have responsibility for Dr. Lenhardt’s patients with rare exceptions. For issues that come up outside of regular office hours, there be a traditional on-call system utilizing a physician group that will include Dr. Lenhardt. He may or may not be on call for any particular evening and medical needs off hours can be covered by a provider who may or may not work at Well Life.

 

You will also have email access to Dr. Lenhardt through the electronic medical record system. For those in the Wellness Plan, emails will only be addressed during regular business hours. If you wish to send secure e-mail communications to, and receive secure e-mail communication responses from, Dr. Lenhardt, and/or his employees, agents, co-workers or representatives, you must utilize the electronic medical record’s electronic communication system for which you will be given instructions. You should be aware that unlike the secure message service provided through the electronic medical record, traditional e-mail is not a secure method for sending or receiving potentially sensitive personal health information. You also acknowledge and understand that e-mail in any form is not a good method for urgent or time-sensitive communications. In the event a communication is time-sensitive, you must communicate with Dr. Lenhardt or the staff at Well Life by telephone or in person. You acknowledge and understand that, at the discretion of Dr. Lenhardt, or Well Life, your e-mail may become part of your medical record.

 

Membership Fees:  Your Membership Fee and payment structure is described in Exhibit A attached to this Membership Agreement.

 

Medical Services/Exclusions from Program: In addition to the Services outlined above which you will receive as part of the Program, Dr. Lenhardt will provide general internal, family and/or holistic medicine services to you as a regular patient. Except for the Services that you receive as part of the Program, you and/or your insurer (whether commercial, Medicare or other third-party payor) will be financially responsible for paying for all medical services received by you from Dr. Lenhardt or the staff at Well Life. This means that while access to a same or next-day appointment is included in the Services that you receive as part of the Program, you or your insurer/Medicare will be responsible for the cost of the medical care provided in that appointment.

 

Co-Payments/Other Out of Pocket Costs: Your payment of the Membership Fee will not affect the co-payments, co-insurance or deductibles that you are required to pay pursuant to the terms of your insurance coverage/Medicare. You will continue to be financially responsible for any co-payments, co-insurance or deductible amounts required by your insurer/Medicare for those services outside the Services that you receive as part of the Program.

 

Term and Termination: This Membership Agreement has an initial one (1) year term beginning on the date set forth on Exhibit A, and, unless and until terminated as set forth below, shall automatically renew for additional one (1) year terms.

 

You or Dr. Lenhardt may terminate this Agreement at any time upon 30 days’ written notice. If you or Dr. Lenhardt terminate this Agreement for any reason, you will be entitled to a prorated refund for any fees paid in full in advance. (Members can otherwise choose to pay in monthly installments if so desired and, under this payment arrangement, any monthly fees already paid will not be refunded.)

 

Vacations/Absences: All of your office visits will be with Andrew Lenhardt, MD, except when he is away on vacation, ill or attending a conference. For those times, he will be covered by Frank Harte, MD, and other appropriately qualified medical staff from Well Life.

 

Entire Agreement: The undersigned agrees to the terms of this Agreement, all of which expressed herein. There are no promises or representations between you and Dr. Lenhardt except as set forth herein.

 

Notices: Any communication required or permitted to be sent under this Agreement shall be in writing and sent via U.S. mail to the addresses set forth in Exhibit A. Any change in address shall be communicated in accordance with the provisions of this section.

 

Billing: Membership fees are charged annually or monthly as elected by the Member and reflected on Exhibit A and must be paid within thirty (30) days. Monthly billing will start a month prior to the date each patient becomes an official patient under Dr. Lenhardt, e.g. for services that start March 1, 2017, the first payment will be due February 1, 2017. The monthly fee will continue to be billed a month in advance until the agreement is nullified either by the member or by Dr. Lenhardt. Copayments, deductibles and coinsurance shall be paid upon receipt of an invoice from Well Life and/or Dr. Lenhardt. Failure to keep up with annual or monthly payments for any and all portions of the Agreement may result in termination of this Agreement following written notice from Dr. Lenhardt.

 

Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the Commonwealth of Massachusetts without regard to Massachusetts’ choice of law provisions.

 

 

 

 

________________________________________              ___________

Andrew Lenhardt, M.D.                                               Date

 

 

 

________________________________________              ___________

Member Name:                                                              Date

 

 

________________________________________              ___________

Member Name:                                                              Date

 

 

Exhibit A

 

 

Effective Date: ______________

 

 

Check applicable Membership Fee:

 

 

________$75 per month for individuals in the Wellness Plan

 

 

________ $200 per month for a family in the Wellness Plan that would include two adults and all children between 10 and 21 years old

 

 

 

Check applicable payment structure:

 

_______ Annual in Full

 

_______ Monthly (12 equal installments)

 

 

Credit Card Number ______________________ Exp Date _________ CVV ______

 

Name on Credit Card __________________________________________

 

 

Name(s) of Member(s)                              Address for Member(s):

 

 

_______________________                       _________________________

 

 

_______________________                       _________________________

 

 

_______________________                       _________________________

To view, sign, and return the form:

 

1. Click on the link to view the agreement, if necessary download the document.

 

2. Open the document.

 

3. Please fill-in all blue areas—including initially each page and filling in the sections on the last two pages.

 

4. Save or print the document once it is completed.

 

5. Please return the signed versions of the file by email, or mail the printed versions.

To view, sign and return the form:

 

1. Click on the link to view the agreement and download the document.

 

2. Open the document.

 

3. Please fill-in all blue areas—including initially each page and filling in the sections on the last two pages.

 

4. Save or print the document once it is completed.

 

5. Please return the signed versions of the file by email, or mail the printed versions.

Andrew Lenhardt, MD

Personalized Medicine

Membership Agreement

CONCIERGE WELLNESS PROGRAM

2 First Avenue Suite 215

Peabody, Massachusetts 01960

978.473.2001 |   dr.a.lenhardt@gmail.com