Patient Agreement
This is an Agreement between Cornerstone Family Medicine L.L.C., a Missouri professional corporation, located at 809 Medical Park Drive, Mexico, Missouri 65265, and 500 Market St. Suite 300, Fulton Mo, 65251, (Cornerstone) , Alex Finck, MD, Mary Pat Bunch, NP, and Kelsey Tillman, NP (Physician) in their capacity as an agent of Cornerstone, and you, (Patient).
Background
The Physician, who specializes in family medicine, delivers care on behalf Cornerstone, at the address set forth above and virtually. In exchange for certain fees paid by You, Cornerstone, through its Physicians, agrees to provide Patient with the Services described in this Agreement on the terms and conditions set forth in this Agreement.
Definitions
- Patient. A patient is defined as those persons for whom the Physician shall provide Services, and who are signatories to, or listed on the documents attached as Appendix 1, and incorporated by reference, to this agreement
- Services. As used in this Agreement, the term Services, shall mean a package of services, both medical and non-Medical, and certain amenities ( collectively “Services”), which are offered by Cornerstone, and set forth in Appendix 1. Virtual memberships are covered in Appendix 2.
- Terms. This agreement shall commence on the date signed by the parties below and shall continue for a period of one month, automatically renewed.
- Fees. In exchange for the services described herein, Patient agrees to pay Cornerstone, the amount as set forth in Appendix 1, attached. This fee is payable upon execution of this agreement, and is in payment for the services provided to Patient during the term of this Agreement. If this Agreement is canceled by either party before the agreement termination date, then Cornerstone shall refund the Patient’s pro-rated share of the original payment, remaining after deducting individual charges for services rendered to Patient up to cancellation.
- Non-Participation in Insurance. Patient acknowledges that neither Cornerstone, nor the Physician, participate in any health insurance or HMO plans or panels, including Medicare.
Neither of the above make any representations whatsoever that any fees paid under this Agreement are covered by your health insurance or other third-party payment plans applicable to the Patient. The Patient shall retain full and complete responsibility for any such determination. This agreement acknowledges your understanding that the Physician does not bill Medicare, and as a result, Medicare will not be billed by Cornerstone nor by the Physician for any services provided for you by the Physician. You agree not to bill Medicare or attempt Medicare reimbursement for any such services.
- Insurance or Other Medical Coverage. Patient acknowledges and understands that this Agreement is not an insurance plan, and not a substitute for health insurance or other health plan coverage (such as membership in an HMO). It will not cover hospital services, or any services not personally provided by Cornerstone, or its Physicians. Patient acknowledges that Cornerstone has advised that patient obtain or keep in full force such health insurance policy(ies) or plans that will cover Patient for general healthcare costs. Patient acknowledges that this Agreement is not a contract that provides health insurance, and this Agreement is not intended to replace any existing or future health insurance or health plan coverage that Patient may carry.
- Term; Termination. This Agreement will commence on the date first written above and will extend monthly thereafter. Notwithstanding the above, both Patient and CORNERSTONE shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination, upon giving 30 days prior written notice to the other party. Unless previously terminated as set forth above, at the expiration of the initial one-month term (and each succeeding monthly term), the Agreement will automatically renew for successive monthly terms upon the payment of the monthly fee at the end of the contract month.
- Communications. You acknowledge that communications with the Physician using e-mail, facsimile, video chat, instant messaging, and cell phone are not guaranteed to be secure or confidential methods of communications. As such, you expressly waive the Physician’s obligation to guarantee confidentiality with respect to correspondence using such means of communication. You acknowledge that all such communications may become a part of your medical records.
By providing Patient’s e-mail address on the attached Appendix 1 , Patient authorizes the Cornerstone, and its Physicians to communicate with Patient by e-mail regarding Patient’s “protected health information” (PHI) (as that term is defined in the Health Insurance Portability and Accountability Act ( HIPAA) of 1996 and it’s implementing regulations) By inserting Patient’s e-mail address in Exhibit 1, Patient acknowledges that:
a. E-mail is not necessarily a secure medium for sending or receiving PHI and, there is always a possibility that a third party may gain access;
b. Although and the Physician will make all reasonable efforts to keep e-mail communications confidential and secure, neither Cornerstone, nor the Physician can assure or guarantee the absolute confidentiality of e-mail communications;
c. In the discretion of the Physician, e-mail communications may be made a part of Patient’s permanent medical record; and,
d. Patient understands and agrees that E-mail is not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation in which the member could reasonably expect to develop into an emergency, Member shall call 911 or the nearest Emergency room, and follow the directions of emergency personnel.
If Patient does not receive a response to an e-mail message within one day, Patient agrees to use another means of communication to contact the Physician. Neither Cornerstone, nor the Physician will be liable to Patient for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient 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 the Practice’s computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of e-mail communications by a third party; or (v) your failure to comply with the guidelines regarding use of e-mail communications set forth in this paragraph.
- Change of Law. If there is a change of any law, regulation or rule, federal, state or local, which affects the Agreement including these Terms & Conditions, which are incorporated by reference in the Agreement, or the activities of either party under the Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and either party reasonably believes in good faith that the change will have a substantial adverse effect on that party’s rights, obligations or operations associated with the Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms of the Agreement including these Terms & Conditions. If the parties are unable to reach an agreement concerning the modification of the Agreement within forty-five days after of date of the effective date of change, then either party may immediately terminate the Agreement by written notice to the other party.
- Severability. If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of the Agreement shall not be affected, and 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.
- Reimbursement for services rendered. If this Agreement is held to be invalid for any reason, and if Cornerstone is therefore required to refund all or any portion of the monthly fees paid by Patient, Patient agrees to pay Cornerstone an amount equal to the reasonable value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid.
- 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 Physician may unilaterally amend this Agreement to the extent required by federal, state, or local law or regulation (“Applicable Law”) by sending You 30 days advance written notice of any such change. 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 Cornerstone, except that Patient shall initial any such change at Cornerstone’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, 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.
- Assignment. This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient.
- Relationship of Parties. Patient and the Physician intend and agree that the Physician, in performing his duties under this Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and/or the United States Department of Labor, and the Physician shall have exclusive control of his work and the manner in which it is performed.
- Legal Significance. Patient acknowledges that this Agreement is a legal document and creates certain rights and responsibilities. Patient also acknowledges having had a reasonable time to seek legal advice regarding the Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of the Agreement.
- Miscellaneous; This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted. Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text.
- Entire Agreement: This Agreement contains the entire agreement between the parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement.
- Jurisdiction: This Agreement shall be governed and construed under the laws of the State of Missouri and All disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for Cornerstone’ address in Mexico, Missouri.
- SERVICE. All written notices are deemed served if sent to the address of the party written above or appearing in Exhibit A by first class U.S. mail.
The parties have signed duplicate counterparts of this Agreement on the date first written above.
Appendix 1
Services and Payment Terms
- Medical Services. As used in this Agreement, the term Medical Services shall mean those medical services that the Physician, himself is permitted to perform under the laws of the State of Missouri and that are consistent with his training and experience as a family medicine physician, as the case may be. Patient shall also be entitled to an annual in-depth “wellness examination and evaluation.”
- The Physician may from time to time, due to vacations, sick days, and other similar situations, not be available to provide the services referred to above in this paragraph 1. During such times, Patient’s calls to the Physician, or to the Physician’s office, will be directed to a physician who is “covering” for the Physician during his absence. Cornerstone will make every effort to arrange for coverage, but cannot guarantee such coverage.
- Non-Medical, Personalized Services. Cornerstone shall also provide Patient with the following non- medical services (“ Non-Medical Services ”):
a. 24/7 Access. Patient shall have access to the Physician via instant messaging and video chat. Patient shall also have direct telephone access to the Physician on a twenty-four hour per day, seven day per week basis. Patient shall be given a phone number where patient may reach the Physician directly around the clock. During the Physician’s absence for vacations, continuing medical education, illness, emergencies, or days off, Cornerstone will provide the services of an appropriate licensed healthcare provider for assistance in obtaining medical services. Patient shall be given instructions as to how to contact such healthcare provider. Such provider shall be available to Patient to the same extent as would the Physician, however provider shall be contacted through main clinic number rather than through a direct phone line. Patient should refrain from contacting Physician after business hours for non-urgent medical conditions. The Physician is expected to reply to texts and calls within a reasonable amount of time, appropriate for the medical condition in question.
b. E-Mail Access. Patient shall be given the Physician’s e-mail address to which non-urgent communications can be addressed. Such communications shall be dealt with by the Physician or staff member of the Practice in a timely manner. Patient understands and agrees that email and the internet should never be used to access medical care in the event of an emergency, or any situation that Patient could reasonably expect may develop into an emergency. Patient agrees that in such situations, when a Patient cannot speak to Physician immediately in person or by telephone, that Patient shall call 911 or the nearest emergency medical assistance provider, and follow the directions of emergency medical personnel.
c. No Wait or Minimal wait Appointments. Every effort shall be made to assure that Patient is seen by the Physician immediately upon arriving for a scheduled office visit or after only a minimal wait.
d. Home or Office Visits. Patient may request that the Physician see Patient in Patient’s home or office, and in situations where the Physician considers such a visit reasonably necessary and appropriate, he will make every reasonable effort to comply with Patient’s request.
e. Specialists. CORNERSTONE Physician shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialists fees or fees due to any medical professional other than the Cornerstone Physician.
- Fees
(a) Monthly membership fee will be $55 per month for patients aged 19 and older and $22 per month for patients 0 to 18. Virtual membership is $42 per month. Initial sign up requires a 3-month subscription minimum. Fees are subject to change.
(b) Service fees will be charged for procedures and additional services such as, but not limited to, point of care testing, in-office evaluation, procedures and testing.
(c) Medication fees and mailing fees will also be charged for dispensed medications and mailed medications.
- Grounds for termination:
(a) At times, the physician-patient relationship might be strained to the point of needing termination for the best of that patient’s care.
(b) Grounds for termination include but are not limited to:
- inappropriate use of 24/7 hour access to Cornerstone providers
- rude/disparaging comments to Cornerstone staff or other patients
- Threatening behavior
- Neglecting to pay bills due to Cornerstone Family Medicine in a timely manner
(c) If the physician-patient relationship is terminated, Cornerstone will provide 30 days of coverage for urgent and emergent care and direction. During that time, the patient is
Appendix 2
Virtual Membership
- Consent to virtual treatment:
a. I am over the age of 18. If am under the age of 18 but older than 13, I represent and warrant that my parent or legal guardian authorized to consent on my behalf has read the terms of this Informed Consent to Virtual Care Services (this “Consent”) and accepted them on my behalf.
b. I am not under the influence of any medications or other substances that could impair my understanding of the information in this Consent. I have had sufficient time to read and understand the information provided in the Cornerstone Family Medicine Terms of Service regarding virtual care. I have had the opportunity to discuss this Consent with my treating Professional providing virtual primary care services (“Virtual Care Services”) through Cornerstone Family Medicine. I have been given all of the opportunity I require to ask any and all of my questions, and such questions have been answered to my satisfaction in words I understand.
c. I grant my permission for Virtual Care Services to be performed by Cornerstone Family Medicine’s employed and contracted providers and employees (collectively, my “Professionals” and each, my “Professional”). I authorize Cornerstone Family Medicine and the Professionals to release the information gained from the Virtual Care Services to my collaborating physician(s), health care provider, and insurance company (to assist with claim reimbursement if relevant) unless I specifically object to such release. I understand and agree that the information in this file will be kept for a period that is required by applicable federal and state law.
d. I understand that I have the right to withhold or withdraw my consent to receive Virtual Care Services at any time, without affecting my right to future care or treatment.
- Virtual services and in-person services:
a. I acknowledge and accept that the physical examination portion of the Virtual Care Services, if any, will be delivered wholly virtually through Cornerstone Family Medicine in reliance upon video, images, telephone consultations, texts, emails, questionnaire, medical records and/or otherwise. Physical visits will cost $50 copay at time of service, in addition to the monthly fee of $42 for virtual services. I accept this, with full knowledge, of all potential benefits and consequences from virtual care and deem this method of physical examination appropriate and complete, but I may not, because as with all medical or health care services provided, no results or outcomes can be guaranteed. In fact, as with all medical or health care services provided, I may be subject to virtual care that may cause some harm, including potentially serious harm.
b. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My Professional has explained these alternatives to my satisfaction.
c. In-person services are available at request for an additional $50 copay at time of service. Pricing subject to change.
d. I acknowledge that, in the exercise of his/her clinical judgment, a Professional may determine: (1) that the nature of my problem is such that it is not professionally appropriate to assist me with that problem through virtual care; or (2) that it may not be lawful for the Professional to diagnose or treat me virtually; or (3) both. Should the Professional make any such determination that they will be unable to assist me virtually, he/she will confer with me about other possible approaches to handling my medical problems, such as referring me to my primary care physician. Additionally, the patient retains the option to switch the $55 per month membership which includes in-person services.
- Patient responsibilities:
a. I understand that it is my duty to inform my primary care provider of any electronic interactions regarding my health care that I may have with other health care providers.
b. I will provide my Professional and Cornerstone Family Medicine with the names and contact information for other relevant healthcare providers for me, and my Professional may communicate with them. It is my responsibility to provide accurate information and to keep it updated. I understand that email and text are not secure means of communication, and give my permission for my Professional to send and receive texts and emails that may contain my Personal Health Information (“PHI”).
c. I understand that it is my choice to have someone else present during a Virtual Care Services session, and that anyone who sits in on the virtual session will have access to my healthcare information and my confidentiality may not be guaranteed. I understand that if I include any third party on an email or text with Cornerstone Family Medicine I am granting permission for Cornerstone Family Medicine to communicate my health information with that third party. Cornerstone Family Medicine and/or the Professional will not initiate inclusion of any third party on an email or text. I acknowledge that Cornerstone Family Medicine and/or the Professional is not responsible for any breach of confidentiality made by any person present I invite to be present during a visit, or added by me as a third party.
- Patient Privacy:
a. I understand that Cornerstone Family Medicine may share de-identified data with third parties such as research organizations, drug manufacturers, or others. Cornerstone Family Medicine will never share my individually identifiable personal information, including PHI, unless I have provided authorization or as otherwise permitted by law.
b. I understand that virtual care may involve electronic communication of my personal medical information to other medical professionals who may be located in other areas, including out of state. I understand that the laws that protect privacy and the confidentiality of medical information also apply to virtual care, and that no information obtained in receiving virtual care, which identifies me, will be disclosed to researchers or other entities without my consent. I also acknowledge, however, that the security and privacy of electronic communications cannot be guaranteed.
c. I have read and understand the Privacy Policy and the Notice of Privacy Practices.
d. I understand that I have the right to inspect all information obtained and recorded in the course of a virtual care interaction, including any of my medical records, and may receive copies of this information for a reasonable fee.
By acknowledging completing the online enrollment, I hereby authorize Cornerstone Family Medicine and any Professional performing the Virtual Care Services through the Site or the App to provide care to me virtually in the course of my engagement and treatment, as applicable.
I agree that my electronic agreement to this Consent is equivalent to the signature of a patient. I understand a copy of this Consent is available by printing this document or by request.
Appendix 3
Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Uses and Disclosures
The following categories describe the different ways in which we may use and disclose your individually identifiable health information, unless you object:
Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members. Additionally, we may disclose your health information to others who may assist in your care, such as other healthcare providers, your spouse, your children or parent.
Payment. Your health information may be used in order to bill and collect payment for the services and items you may receive from us. For example, we may use and disclose your health information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your health information to bill you directly for services and items.
Health care operations. Your health information may be used as necessary to support the day to day activities and management of Cornerstone Family Medicine. For example, information on the services you received may be used to support budgeting and financial reporting, activities to evaluate and promote quality, to develop protocols and clinical guidelines, to develop training programs, and to aid in credentialing medical review, legal services, and insurance.
Appointment reminders. Your health information will be used by our staff to contact you and send you appointment reminders.
Information about treatments. Your health information may be used to send you information that you may find interesting on the treatment and management of your medical condition. We may also send you information describing other health related products and services that we believe may interest you.
Law enforcement. Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting.
Release of Information to Family/Friends. Our practice may release your health information to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child for an appointment. In this example, the babysitter or friend may have access to this child’s medical information.
Patient mass communication. We may use your name and email address(es) and/or text numbers to contact you with bulk messaging. For instance, to share new promotions for the clinic, to send clinic newsletters, or to notify you of a physician’s upcoming absence, such as for vacations.
Other uses and disclosures in certain special circumstances.
- Public Health Risks – (i.e. vital statistics, child abuse/neglect, exposure to communicable diseases, reporting reactions to drugs or problems with products or devices.)
- Health Oversight Activities
- Lawsuits and Similar Proceedings – May use or disclose in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding or in response to a discovery request, subpoena, or other lawful process.
- Deceased Patients – may be required to release to a medical examiner or coroner. If necessary, we may also release information to a funeral director in order for them to perform their jobs.
- Organ and Tissue Donation
- Serious Threats to Health or Safety
- Military - If you are a member of the U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
- National Security
- Inmates – Our practice may disclose your health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure would be necessary for the institution to provide health care services to you, for the safety and security of the institution, and/or to protect your health and safety or the health and safety of others.
- Worker’s Compensation
Disclosures of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before your notified us of your decision to revoke your authorization.
Your Rights
You have certain rights under the federal privacy standards. These include:
- The right to request restrictions on the use and disclosure of your protected health information for treatment, payment, or health care operations. You have the right to restrict our disclosure to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do not agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. You must make your request in writing to the attention of the Privacy Officer. Your request must be described in a clear and concise fashion: a) the information you wish restricted; b) whether you are requesting to limit our practice’s use, disclosure or both; c) to whom you want the limits to apply.
- The right to receive confidential communications concerning your medical condition and treatment
- The right to inspect and copy your protected health information. We will provide a copy or summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of the denial.
- The right to amend or submit corrections to your protected health information. This request must be made in writing and submitted to Privacy Officer with reasons to support your request. We may deny your request if you ask us to amend information that is in our opinion: a) accurate and complete; b) not part of the health information kept by or for the practice; c) not part of the health information which you are permitted to inspect and copy; or d) not created by our practice, unless the individual or entity that created it is not available to amend the information. We will provide a written explanation for any denial in 60 days.
- The right to receive an accounting of how and to whom your protected health information has been disclosed. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any that you asked us to make). We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
- The right to receive a printed copy of this notice, even if you have agreed to receive the notice electronically.
Requests to Inspect Protected Health Information
You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting your physician and/or privacy officer. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.
Cornerstone Family Medicine Duties
We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice.
Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.
Complaints
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:
Cornerstone Family Medicine
Attn: Privacy Officer
809 Medical Park Dr, Suite 101
Mexico, Missouri 65265
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.
Appendix 3
Why we are asking for your consent
Cornerstone Family Medicine uses Artificial Intelligence (AI) tools in the exam room and during clinical encounters to support and enhance your care. These tools may listen to and transcribe portions of our conversation, draft and organize clinical notes, summarize your visit, assist with documentation in your medical record, and perform other tasks that help your provider focus more directly on you and less on a keyboard.
How your information is protected
All AI tools used by Cornerstone Family Medicine are HIPAA-compliant. Information processed by these tools is handled in accordance with our Notice of Privacy Practices and applicable federal and state law. Your provider reviews AI-generated content before it is added to your medical record. AI tools support, but do not replace, your provider’s clinical judgment.
What you are agreeing to
By signing below, you acknowledge that you have read this notice and consent to the use of HIPAA-compliant AI tools during your care at Cornerstone Family Medicine, including for:
- Listening to and transcribing portions of clinical conversations,
- Drafting, organizing, and summarizing clinical notes and visit summaries,
- Assisting with documentation in your medical record, and
- Other related tasks that support your treatment and the operation of your care team.
Your right to decline or withdraw consent
You may decline or withdraw this consent at any time. If you do not wish for AI tools to be used during your visits, please notify the front desk or your provider in writing or verbally. Your decision will not affect your access to care at Cornerstone Family Medicine.
