- The Dash Doc provides access to membership-based medical care that is provided through The I.V. Medical Doctor, P.C., The I.V. Doctor of California, P.C., and The I.V. Doctor, P.C. (the “Practices”) on a 24/7/365 basis (collectively, the “Practice Medical Services”).
- The Dash Doc provides certain non-medical related services (the “Dash Doc Services”), including access to Practice Medical Services:
The following Practice Medical Services are provided by the Practice at no additional charge:
24/7/365 Immediate Remote Telemedicine Consultation
- Certain Practice Medical Services incur an additional fee from the Practice, including, but not limited to:
Premium Services, including House Calls
Medical Interventions, e.g.: IVs, Medication & Sutures
Medical Diagnostic Imaging (e.g.: CT, MRI, US, XRay)
Though we cannot guarantee insurance coverage, the Practice will submit claims for non-covered medical services as an out of network provider to your insurance carrier(s) for potential reimbursement.
- Any services provided by specialist partners or hospital partners are billed separately and directly by the partner.
- In order to obtain Dash Doc Services, You desire to become a member of the Dash Doc in exchange for an annual fee of $12,000, based on a standard rate of $1,000 per month per member.
- The purpose of this Agreement is to set forth the terms and conditions of how the Dash Doc Services will be furnished to You by the Dash Doc. You and the Dash Doc therefore agree to the Terms & Conditions on the subsequent pages. For the avoidance of doubt, the Dash Doc only provides access to the Practice Medical Services and is not itself a provider of medical services and does not provide the Practice Medical Services. The Practice Medical Services are provided exclusively by the Practice, which is affiliated with the Dash Doc but is independently owned and operated. The Dash Doc has absolutely no control or supervision over or responsibility for any aspects of the practice of medicine or the provision of medical services to Members.
TERMS & CONDITIONS
1. Services. On a best efforts basis, Dash Doc will provide You with access to the following Practice Medical services (it being expressly acknowledged and agreed that Dash Doc is in no way engaged in the practice of medicine and that any Dash Doc Services that are medical in nature will be exclusively provided by Practices):
1.1 Dash Doc Services
1.1.A 24/7/365 Access. Dash Doc will provide you with access to the Practices’ scheduling line (each a “Schedule”) twenty-four (24) hours per day, seven (7) days per week, three hundred sixty five (365) days per year, in order to be seen by a Practice Physician (a “Physician”).
1.1.B Immediate Physician Consultations. You will have almost immediate access to a Physician for most encounters at no additional cost.
1.1.C Remote Telemedicine Consultations. If You desire a remote consultation by telephone or video, Dash Doc will coordinate having a Physician remote consultation available on a twenty-four (24) hours per day, seven (7) days per week, three hundred sixty five (365) days per year basis, at no additional cost, as medically appropriate.
1.1.D Expedited Access to a Network of Vetted Specialists. In the event that Your illness requires treatment by a medical or surgical specialist, the Dash Doc has an extensive network of specialists who will be referred to you (the “Referred Provider”). Neither the Dash Doc nor practice receive any monetary compensation from the Referred Provider. You will be responsible for any fees that the Referred Provider may have.
1.1.E Emergency Global Care Coordination. In the event that you require care beyond Telemedicine our VIP staff will assist in coordinating your care. From foreign state evacuation or hospitalization, the Dash Doc will assist in managing care on your behalf. Additional fees will apply (i.e. transportation via ambulance, helicopter, jet).
1.1.F Access to Medical Interventions. You will have rapid access to medical intervention and treatment as needed, including IVs , sutures, and medications.
1.1.G Access to Premium Services. Dash Doc members can gain access to Practice premium services at an additional cost, including home visits, executive wellness packages and other services.
1.2 Medical Services. All Practice Medical Services will be provided through the Practices. Please note: the Practices are opted-out of Medicare and provide Medical Services as out-of- network providers.
2.1 Annual Membership Fees. As a condition precedent to becoming a member of the Dash Doc and having access to Dash Doc Services, You hereby agree to pay the Dash Doc the membership fees (i.e., for each Member) that are agreed on page 1 of this agreement by both parties (the “Annual Membership Fees”). The Annual Membership Fees will be split into twelve equal payments and apply for the one (1) year period following the Effective Date and You must make a renewal fee payment equal to the then prevailing Annual Membership Fees on each one (1) year anniversary of the Effective Date throughout the Term. By way of clarification and not limitation, the Primary Member will pay the Annual Membership Fees for each Member annually. The Annual Membership Fees are subject to adjustment by the Dash Doc, which will be updated by the Practices and payable by Member during Member’s next annual installment of the Annual Membership Fees. You must pay the Annual Membership Fees for each Member annually and in full on the Effective Date and on or before each annual anniversary throughout the Term. The Dash Doc reserves the right to (i) terminate this Agreement for Member(s) or (ii) withhold access to Dash Doc facilities for failure to pay any installment of Annual Membership Fees in a timely manner. Should you fail to make timely payment of fees, the Dash Doc may charge late fees of 5% per month of the total amount owed until paid.
2.2 Practice’s Professional Medical Services Fees. Member has read and agrees to the Practices’ payment policies, which detail that Member will pay for all of the Practices’ professional medical services directly (“Practice Professional Fees:”). It is acknowledged and agreed that the Annual Membership Fees are separate and apart from any fees charged by the Practices. By way of clarification, and not limitation, all professional fees will be charged by the Practices through the Practice Professional Fees and all services of specialists (Referred Provider’s) will be pursuant to such specialists’ payment arrangements with You (it also being acknowledged and agreed that such specialists’ professional services are not included in the Annual Membership Fees).
3. Term. This Agreement will commence on the Effective Date and will continue for a period of one (1) year thereafter (the “Initial Term”), unless terminated sooner pursuant to Section 4 below. At the end of the Initial Term, unless earlier terminated pursuant to Section 4 below, this Agreement will continually and automatically renew upon the same terms and conditions for successive one (1) year periods (each, a “Renewal Term”), unless terminated sooner pursuant to Section 4 below. For purposes hereof, the Initial Term and each Renewal Term will be collectively referred to as the “Term”.
4. Termination. You and Dash Doc shall have the absolute and unconditional right to terminate this Agreement, without the showing of any cause, by providing the other Party thirty (30) days prior written notice. If terminated by the Dash Doc, You shall receive the pro rata amount of the Annual Membership Fees for the period of time between the effective date of termination and the next one (1) year anniversary of the Effective Date (the “Refunded Prorata Annual Membership Fees”). The Refunded Prorata Annual Membership Fees shall be paid to You within thirty (30) days of termination.
5. Insurance Coverage of Fee. The Dash Doc makes no representations whatsoever that the fees paid under this Agreement are or are not covered by Your health insurance or other third party payment plans applicable to You or Your family, although such fees are likely NOT covered. You will have the full and complete responsibility for any such determination; provided, however, that irrespective of such determination, You are expressly agreeing to pay the Annual Membership Fees under this Agreement.
6. Insurance or Other Medical Coverage. This Agreement is not a substitute for health insurance or other health plan coverage (such as membership in an HMO). You acknowledge that the Dash Doc and the Practices have advised You to obtain or keep in full force Your health insurance policy(ies) or plans in order to cover You and Your family members for healthcare costs. You acknowledge that this Agreement is not a contract that provides health insurance for you, and this Agreement is not intended to replace any existing or future health insurance or health plan coverage that You may carry for You or Your family.
7. Dependent Members. If You are signing for and on behalf of one or more of Your “dependents” (as such term is defined by the U.S. Internal Revenue Service), You will be responsible under this Agreement as their parent or guardian. You, as the signing Member, agree to indemnify, defend, reimburse and hold harmless Dash Doc, Practices and the Physician for, from, and against any claims of made by, or on behalf of the dependent.
8. Communications. You acknowledge that communications with the Dash Doc using e-mail, facsimile, cell phone, and/or SMS texting are not guaranteed to be secure or confidential methods of communications. As such, You expressly waive the Dash Doc’s obligation to ensure confidentiality with respect to correspondence using such means of communication. You also acknowledge that you have read and agree to the Practices’ policies on communication vie email, text message and phone.
9.1 Limitation of Liability. The Dash Doc’s services are sold “as-is.” Except in the event of willful misconduct, gross negligence, or fraud, the Dash Doc shall not be liable to you, or any person claiming through you, under this engagement letter, under any legal theory, for any amount in excess of the total fees paid by the Dash Doc under this contract or any addendum to which the claim relates. In no event will the Dash Doc be liable to You under this contract under any legal theory for any consequential, indirect, lost profit, punitive, incidental or similar damages relating to or arising from services provided under this contract. The Dash Doc does not warrant that the functions contained in this engagement will be completely uninterrupted or completely error-free. In no event will the Dash Doc be liable to You or any third party for any damages, including, but not limited to service interruptions caused by Acts of God or any other circumstances beyond Dash Doc’s control.
9.2 Notices. Any notice required or permitted under this Agreement will be in writing and will be deemed to have been sufficiently given or served and effective for all purposes when delivered by a nationally recognized overnight delivery service or three (3) days after deposit with the United States Postal Service via certified mail, postage pre-paid, or to Member’s email address addressed as follows:
If to Dash Doc, then to: 53 West 36th St, Suite 204, New York, NY 10018
If to Member, then to: Member Mailing Address
Any Party hereto may change its address of record for receiving notices by giving the other Party written notice of such change in the manner set forth above.
9.3 Waiver. Any waiver of any of the covenants, conditions or provisions of this Agreement must be in writing and signed by the Party against whom enforcement of such waiver is sought. One or more waivers of any covenant, condition or provision of this Agreement will not be construed as a waiver of a subsequent breach or of any other covenant, condition or provision.
9.4 Venue/Consent to Jurisdiction. Subject to the arbitration provisions provided in Section 9.5 below, the Dash Doc and the Practices hereby consent to the exclusive jurisdiction of the State and Federal Courts located in New York County, New York for any and all actions in law or equity arising from this Agreement. The Dash Doc and the Practices hereby waive any objections relating to improper venue or forum non-conveniens to the conduct of any proceeding in any such court.
9.5 Assignment. This Agreement, and any rights You may have under it, may not be assigned or transferred by You.
9.6 Arbitration. Any disputes that arise between the Parties with respect to the performance of this Agreement will be submitted to binding arbitration by the American Arbitration Association (“AAA”) to be determined and resolved by AAA under its Dispute Resolution Rules in effect at the time of submission.
9.6.A Arbitration will be held at a location selected by the Dash Doc in New York County, New York and arbitration will be the exclusive forum for resolving such dispute, controversy or claim. The arbitration will be heard by one (1) arbitrator who must be disinterested, and preferably knowledgeable about the subject matter of this Agreement. The arbitrator will be appointed jointly by the Parties within thirty (30) days following the date on which the arbitration is instituted. If the Parties are unable to agree upon an arbitrator within such thirty (30)-day period, the AAA will select such arbitrator using its standard procedures.
9.6.B The decision of the arbitrator will be final and binding upon the Parties hereto and judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. The arbitrator will not have the power to award any damages excluded by, or in excess of, any damage limitations expressed in this Agreement.
9.6.C If court proceedings to stay litigation or compel arbitration are necessary, the Party who unsuccessfully opposes such proceedings will reimburse and pay all associated costs, expenses and attorneys’ fees that are reasonably incurred by the other Party. In no event will a demand for arbitration be made after the date when institution of a legal or equitable proceeding based on such claim, dispute or other matter in question would be barred by the applicable statute of limitations.
9.6.D All proceedings that take place under or in connection with this provision will be considered confidential information of both Parties and subject to appropriate confidentiality restrictions and/or protective orders.
9.6.E Either Party may apply to the arbitrator to seek injunctive relief until such time as the arbitration award is rendered or the controversy is otherwise resolved.
9.6.F The Parties will share in advancing charges of the AAA and the arbitrator. Notwithstanding, in any action or proceeding to enforce rights under this Agreement, the prevailing party will be entitled to an award of reasonable attorneys’ fees and costs.
9.7 Governing Law. This Agreement will be interpreted, construed and governed according to the substantive laws of the State of New York without regard to principles of conflicts of law.
9.8 Entire Agreement; Construction. This Agreement constitutes the entire agreement of the Parties regarding the subject matter hereof, and all prior representations of the parties, whether written or oral, are merged herein.
9.9 Survival. Any provision of this Agreement which imposes an obligation that extends beyond the termination of the Term will survive the termination of the Term.
9.10 Severability. If any term, provision or condition of this Agreement is held by a court of competent jurisdiction or arbitrator to be invalid, void or unenforceable, that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable and the remainder of the provisions hereof will remain in full force and effect and will in no way be affected, impaired or invalidated as a result of such decision.
9.11 Headings. The headings in this Agreement are for convenience only and will not be construed as a part of the Agreement.
9.12 No Construction Against Drafter. No Party hereto will be considered to be the drafter of this Agreement or any paragraph or term hereof and no presumption will apply to any Party as the “drafter.”
9.13 Counterparts. This Agreement may be executed in two or more counterparts, each of which will be deemed an original, but all of which together will constitute one and the same instrument. Fax, PDF, and electronic signatures will be binding and enforceable as if a physical signature was affixed to Agreement.
9.14 Legal Significance. You acknowledge that this Agreement is a legal document and creates certain rights and responsibilities. You also acknowledge that You have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.
9.15 Amendment. No amendment of this Agreement shall be binding on a Party unless it is made in writing and signed by all the Parties. Notwithstanding the foregoing, the Dash Doc may unilaterally amend this Agreement to the extent required by federal, state, or local law or regulation (“Applicable Law”) by sending You, upon thirty (30) days advance written notice of any such change and may amend the Annual Membership Fees in accordance with the terms of this Agreement. Any such changes are incorporated by reference into this Agreement without the need for signature by the Parties and are effective as of the date established by the Dash Doc, except that You will initial any such change at the Dash Doc’s request. Moreover, if Applicable Law requires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary as determined by the Dash Doc, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been expressly set forth in this Agreement.
The above referenced individual(s) (or such individual(s) on behalf of such individual’s minor child) seeks treatment through The I.V. Medical Doctor, P.C., The I.V. Doctor of California, P.C., and The I.V. Doctor, P.C. (collectively, the “Practice”). The above referenced individual(s) expressly acknowledges and agrees to:
- the provisions below regarding consent to payment,
- the provisions below regarding consent to treatment, and
- the provisions below regarding consent to communications
1. CONSENT TO PAYMENT
Individual agrees that he/she is personally responsible for paying all of Practice Medical Services fees for items and/or services furnished by Practice and its providers (collectively, the “Fees”). Individual further agrees that all Fees are due upon receipt.
Individual expressly acknowledges and agrees that Practice is a private medical provider that has opted out of participating with Medicare and Medicaid and is a non-participating provider in other commercial medical insurances. Individual expressly understands that Individual has the right to obtain Medicare-covered items and services (if Individual is a Medicare eligible beneficiary) from physicians and practitioners who have not opted out of Medicare, and that Individual is not compelled to receive services from Practice; however, notwithstanding the foregoing, Individual desires to obtain services through Practice.
Individual understands that Practice’ Fees are subject to modification by Practice and its providers from time to time without prior notice. Individual expressly acknowledges and agrees that Medicare limits to not apply to what Practice and its providers may charge (i.e., the Fees are not limited by Medicare’s fee schedule).
Individual will provide a credit card for Practice to keep on file, in order to be charged for services furnished by Practice. Individual gives permission to Practice to charge this credit card for any amount due to Practice on or after the date of this Consent Form. The individual certifies that the Individual is an authorized user of this credit card and will not dispute the payment with the credit card company. Practice will provide an itemized bill to the Individual within a reasonable amount of time from when any charge is made.
2. CONSENT TO TREATMENT
You have the right, as a patient, to be informed about your condition and the recommended medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).
This form provides Practice with your permission to perform reasonable and necessary medical examinations, testing and treatment. By agreeing to this Form, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.
You have the right to discuss the treatment plan with your physician about the purpose, potential risks, and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions.
You voluntarily request a physician and other health care providers as deemed necessary to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. You understand that if additional testing, invasive or interventional procedures are recommended, you will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).
You certify that you have read and fully understand the above statements and consent fully and voluntarily to its contents.
3. CONSENT TO COMMUNICATIONS
Individual consents to being contacted by Practice at the phone number provided by the Individual.
Individual authorizes Practice and its providers to communicate with him/her by e-mail regarding his/her “protected health information” (“PHI”) (as that term is defined in the Health Insurance Portability and Accountability Act (“HIPAA”) of 1996 and its implementing regulations) using the individual’s e-mail address shown below. By agreeing, Individual acknowledges that:
- E-mail is not completely a secure medium for sending or receiving PHI because these messages may be addressed to the wrong person or accessed improperly while in storage or during transmission.
- Although Practice and its providers will make reasonable efforts to keep e-mail communications confidential and secure, neither Practice nor its providers can assure or guarantee the confidentiality of e-mail communications.
- E-mail is not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. If Individual does not receive a response to an e-mail message within two (2) days, Individual agrees to use another means of communication to contact the Practice provider. Neither Practice nor the Practice provider will be liable to Individual for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Individual as a result of technical failures, including, but not limited to: (i) technical failures attributable to any internet service provider; (ii) power outages, failure of any electronic messaging software, or failure to properly address e-mail messages; (iii) failure of Practice’ computers or computer network, or faulty telephone or cable data transmission; (iv) any interception of e-mail communications by a third party; or (v) Individual’s failure to comply with the guidelines regarding use of e-mail communications set forth in this paragraph.
VIA TEXT MESSAGE
Individual authorizes Practice and its providers to communicate with him/her by text message regarding his/her PHI (as that term is defined under HIPAA) using the individual’s phone number shown below. By agreeing, Individual acknowledges that:
- SMS texting is not a secure medium for sending or receiving PHI because these messages are not encrypted and may be addressed to the wrong person or accessed improperly while in storage or during transmission, such as being intercepted on public Wi-Fi networks.
- If Individual communicates with his/her Practice provider by SMS texting, Individual consents to the provider responding to him/her in this way, despite the risks stated above, unless Individual states otherwise.
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