Medstar Clinic
6817 Southpoint PKWY STE 1602
Jacksonville, FL 32216
(904) 902-0091
www.medstarjax.com
PARTIES TO THIS AGREEMENT
This Concierge Medicine Membership Agreement ("Agreement") is entered into between:
PROVIDER (Practice):
Practice Name: Medstar Clinic
Address: 6817 Southpoint PKWY STE 1602
Jacksonville FL 32216
Phone: (904) 902-0091
COMPANY (Member):
SECTION 1 - MEMBERSHIP FEE
The membership fee covers the services listed in Section 2. Fees are subject to annual review with 60 days' written notice. The membership fee is not insurance and does not substitute for health insurance coverage.
SECTION 2 - INCLUDED SERVICES
The monthly membership fee entitles the Member to the following services at no additional charge:
SECTION 3 - SERVICES NOT INCLUDED
The following are NOT covered by the membership fee and will be billed separately or referred to appropriate facilities:
Specialist consultations and referrals
Hospitalization, emergency room care, or surgical procedures
Branded/non-generic prescription medications
Advanced imaging (X-ray, MRI, CT, ultrasound)
Specialty laboratory testing beyond the included formulary
Vaccinations and immunizations (unless specified in a separate addendum)
Mental health services and psychiatric care
Durable medical equipment (DME)
Controlled substance.
SECTION 4 - TERM AND TERMINATION
4.1 Agreement Term
This Agreement commences on the Effective Date and continues on a month-to-month basis until terminated by either party in accordance with this Section.
4.2 Termination by Member
The Member may terminate this Agreement at any time by providing thirty (30) days' written notice to the Practice. Membership fees paid for the current billing month are non-refundable. Termination does not relieve the Member of any outstanding balance.
4.3 Termination by Practice
The Practice may terminate this Agreement for any of the following reasons upon thirty (30) days' written notice: (a) non-payment of fees; (b) conduct that is disruptive, threatening, or disrespectful to staff or other patients; (c) violation of any term of this Agreement; or (d) the Practice ceasing operations.
4.4 Immediate Termination
The Practice reserves the right to terminate this Agreement immediately and without notice if the Member engages in fraudulent conduct, threatens physical harm to any staff member, or provides false information material to this Agreement
SECTION 5 - PAYMENT TERMS AND BILLING
5.1 Automatic Payment
By signing this Agreement, Member authorizes the Practice to automatically charge the payment method on file on the 1st of each calendar month. The Member agrees to keep valid payment information on file at all times.
5.2 Late Payments
Payments not received within ten (10) days of the due date may result in suspension of services. A late fee of $ 25.00 may be assessed for each month payment is overdue. Accounts more than thirty (30) days past due may result in termination of this Agreement.
5.3 Fee Adjustments
The Practice may adjust the monthly membership fee upon sixty (60) days' prior written notice to the Member. If the Member does not accept the new fee, the Member may terminate this Agreement without penalty during the notice period.
SECTION 6 - MEMBER RESPONSIBILITIES
Maintain accurate and up-to-date contact and health information.
Provide timely payment of membership fees and any separately billed services.
Attend scheduled appointments or provide at least 24 hours' notice for cancellation.
Treat all Practice staff and other patients with courtesy and respect.
Acknowledge that this Agreement does not replace health insurance; Member is solely responsible for obtaining and maintaining insurance.
Notify the Practice of any changes in health conditions, medications, or emergency contacts.
SECTION 7 - LIMITATION OF LIABILITY AND DISCLAIMER
The Practice agrees to provide services in a professionally competent and ethical manner consistent with accepted standards of medical practice. Nothing in this Agreement limits or waives any rights the Member may have under applicable medical malpractice law.
The Practice is not liable for delays in care resulting from Member's failure to provide accurate information, failure to keep scheduled appointments, or events outside the Practice's reasonable control, including natural disasters or public health emergencies.
SECTION 8 - CONFIDENTIALITY AND PRIVACY
The Practice will maintain the privacy of the Member's protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable state law. The Member will receive a separate Notice of Privacy Practices at enrollment. The Member's medical records will not be shared with third parties without written consent except as required or permitted by law.
SECTION 9 - DISPUTE RESOLUTION
The parties agree to attempt to resolve any dispute arising under this Agreement through good-faith negotiation before initiating formal proceedings. If negotiation is unsuccessful, the parties agree to participate in non-binding mediation prior to pursuing litigation. This Agreement shall be governed by the laws of the State of Florida. Any legal proceedings shall be conducted in Duval County.
SECTION 10 - GENERAL PROVISIONS
10.1 Entire Agreement
This Agreement, together with any exhibits or addenda, constitutes the entire agreement between the parties and supersedes all prior agreements, understandings, or representations regarding its subject matter.
10.2 Amendments
This Agreement may only be amended in writing signed by both parties.
10.3 Severability
If any provision of this Agreement is found invalid or unenforceable, the remaining provisions shall continue in full force and effect.
10.4 Waiver
Failure by either party to enforce any provision of this Agreement shall not constitute a waiver of the right to enforce such provision in the future.
10.5 Notices
All notices required under this Agreement shall be delivered in writing via certified mail or email with delivery confirmation to the addresses set forth in Section 1.
SIGNATURES
By signing below, both parties acknowledge that they have read, understood, and agree to be bound by the terms of this Concierge Medicine Membership Agreement.