Welcome to Quick Doc. We are dedicated to providing you with high quality care and service. Quick Doc has a mission to transform primary health care by refocusing on the unique needs of each individual patient, providing greater access and time with your Quick Doc provider, and simplifying the way we do health care. We regard your understanding of the benefits of our program and our financial policies as an essential element of your care. This Program Agreement (this “Agreement”) outlines the terms and conditions of your participation in our CarePackage Program. By completing your registration and participation in the Program You indicate that you have read, understand, and agree to the following terms:
1. The Parties. This Program Agreement is made by and between Quick Doc, LLC. d/b/a Quick Doc (“Quick Doc” or “We”) and the persons who participate in this Program Agreement as Patients (each a “Patient”, “Your” or “You”).
2. Services. As used in this Agreement, the term Services is defined as a package of medical and non-medical services and amenities (collectively known as “Services”) that are offered by Quick Doc, as more particularly set forth in Schedule A. Quick Doc will provide these Services to you at a level of professionalism that is consistent with your Quick Doc provider’s training and experience as a family your Quick Doc provider.
3. The Program. The Program is defined as the providing of Services to Patient by Quick Doc in exchange for certain fees paid by the Patient under the terms and conditions contained in this Agreement. The services listed on Schedule B (collectively, “Non-Covered Services”) are not offered under the Program by Quick Doc or covered by the Program Fees. If a Quick Doc provider determines you need any Non-Covered Services that we do not provide, we will refer you to another health care provider, coordinate your care, and provide the information reasonably necessary for your medical care to the other healthcare provider. You understand and agree that you are responsible for any and all charges incurred for any health care services performed outside of Quick Doc and or provided by anyone other than a Quick Doc provider, including, without limitation, for any health care provider to which you are referred or any outside testing recommended by your Quick Doc provider.
4. Program Fees. You agree to pay Quick Doc the Enrollment fee as well as the monthly program fee as detailed on the checkout page (collectively, the “Program Fees”) in advance on the first day of each month while this Program Agreement is in effect. Quick Doc accepts credit/debit cards for the enrollment fee and the initial month’s Program Fee. After the initial month, your monthly Program Fee will be processed through automatic funds transfer (AFT) through credit/debit card transaction. Payment of your monthly program fee will be automatically deducted from your credit/debit card on the first day of each month during the term of this Agreement. If your monthly program fee is rejected by your banking institution or credit/debit card company, you will be charged a $25 fee for each such rejection. Given the rising costs of health care, Quick Doc reserves the right to increase the Program Fees from time to time, but will do so no more than once a calendar year and you will be notified at least sixty (60) days in advance of any Program Fees increase.
5. Termination.
5.1 By You. You may terminate your participation in the Program at any time by sending a written notice to Quick Doc at least thirty (30) days prior to the first day of the month for which you wish your Program participation to terminate. If you elect to terminate your participation in the Program, you understand and agree to select a new primary care your Quick Doc provider before your termination date and notify Quick Doc of the name of your new primary care your Quick Doc provider. However, your failure to find a new primary care your Quick Doc provider, or not notifying Quick Doc of such, will not result in continued obligation of Quick Doc or your Quick Doc provider to treat you beyond date of termination of this Agreement. With your written authorization, Quick Doc will transfer your medical records maintained by Quick Doc to your new primary care provider. If you are dissatisfied with any of Services provided to you under this Agreement, your right to terminate this Agreement will be your only remedy at law or in equity (subject to any rights that are non-waivable by law). If you terminate your participation in the Program and later determine to renew your participation in the Program, you may be required to pay a re-enrollment fee as determined by Quick Doc in its sole discretion. Quick Doc reserves the right at all times to determine, in its sole discretion, whether to accept any patient into the Program.
5.2 By Quick Doc. If your Quick Doc provider determines that he/she is unable or unwilling to provide any of the Services to you, for any reason, Quick Doc may terminate this Program Agreement upon not less than thirty (30) days’ written notice to you. Quick Doc will provide you with a prorated reimbursement of any fees paid in advance for the month in which such termination occurs as reasonably calculated by Quick Doc. In addition, Quick Doc may terminate this Program Agreement at any time by providing written notice of termination “for cause”, including, without limitation, your fraudulent, abusive or violent behavior, lying, repeated episodes of non-compliance with treatment recommendations, nonpayment for services received, or any failure of the patient-your Quick Doc provider relationship, as determined by your Quick Doc provider.
6. Not Insurance. This Agreement is not a contract of insurance. You acknowledge and agree that this Program is not an insurance plan, is not a substitute for health insurance or other health plan coverage (such as membership in an HMO), and is not intended to replace any existing or future health insurance
plan that you may carry.
7. Insurance/Medicare.
7.1 Non-Participation in Insurance. The Program is designed to provide enhanced health care access, cost efficiency and transparency by lessening the administrative burdens that accompany an insurance-based practice. The Program works best for patients who have no insurance or who have high
deductible plans. We will not file insurance claims on your behalf. You understand that your Program Fees or any other fees under the Program may not be covered or otherwise reimbursable by any health insurance provider and agree that you are solely responsible for payment of your Program Fees regardless
of the terms of any insurance coverage. If you have insurance coverage, you agree that you will not file a claim for the Program Fees. If you have insurance (e.g., a high deductible plan), you acknowledge that it is your responsibility to understand the terms of your insurance coverage, if any, including which medical services are covered; how Program Fees affect your deductible if at all; where services can be performed; whether any other provider to whom you are referred is in-network; whether your employer has any specific guidelines regarding network providers; the amounts of any deductibles, copayments, or coinsurance; and an understanding of which referrals, if any, are required.
7.2 Federal Healthcare Programs. The Program is not open to any patients otherwise covered by a federal healthcare program. By signing this Agreement, you specifically represent that you are not eligible for Medicare, nor are you a beneficiary or participant in the Medicare program, any Medicare Advantage plan, the Medicaid program, Tri-Care, State Children’s Health Insurance Program (SCHIP), the Veterans Health Administration (VHA ) program, the Indian Health Service (HIS) program, the Federal Employees Health Benefits (FEHB) program, or any other program which receives federal health care funding.
8. Communications.
8.1 You understand that communications with Quick Doc and your Quick Doc provider using email, facsimile, text, instant messaging, video chat, cell phone and other forms of electronic communication are not guaranteed to be secure or confidential methods of communication. As such, you expressly consent to the use of these forms of communication by Quick Doc and your Quick Doc provider in connection with the Services provided under this Agreement and agree to hold Quick Doc and your Quick Doc provider harmless with respect to unauthorized access to such electronic communications between you and your Quick Doc provider. Patient further acknowledges that, at the discretion of your Quick Doc provider, all such electronic communications may become part of Patient’s medical records.
8.2 By providing your email address, you authorize Quick Doc and your Quick Doc provider to communicate with you by email regarding your “protected health information” (PHI), as the term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulations. By providing your email address, you acknowledge that email is not necessarily a secure medium for sending or receiving PHI, and there is always a possibility that a third party may gain access to your PHI. You understand and agree that email 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 YOU COULD REASONABLY EXPECT TO DEVELOP INTO AN EMERGENCY, YOU AGREE TO CALL 911 OR THE NEAREST EMERGENCY DEPARTMENT, AND FOLLOW THE DIRECTIONS OF EMERGENCY PERSONNEL.
8.3 If you do not receive a response to an email or text message within one day, you agree to use another means of communication to contact your Quick Doc provider. Neither Quick Doc nor your Quick Doc provider will be liable to you for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to your email or text message for any reason, including, but not limited to delay resulting from: (a) technical failures attributable to any internet service providers; (b) power outages, failure of any electronic messaging software, or failure to properly address email or text messages; (c) failure of
the computers or computer network of Quick Doc or your Quick Doc provider, or faulty telephone or cable data transmission; (d) any interception of email or text communications by a third party; or (e) your failure to comply with the guidelines regarding use of email or text communications set forth in this Agreement.
9. Miscellaneous.
9.1 Entire Agreement. This Agreement sets forth our entire understanding with respect to the medical services you receive at Quick Doc and your participation in the Program and supersedes all existing agreements between us concerning them.
9.2 Amendments. You may not make any amendment to this Agreement unless it is made in writing and signed by all the parties. Notwithstanding the foregoing, Quick Doc may unilaterally amend this Agreement without your signature for any reason, in our sole discretion, including to the extent required by federal, state, or local law or regulation (“Applicable Law”). Quick Doc will provide you written notice of any such amendment, which shall be effective as of the date adopted by Quick Doc.
9.3 Reimbursement for Services Rendered. If this Agreement is held to be invalid for any reason, and Quick Doc is required to refund all or any portion of the Program Fees or other fees paid by Patient, Patient agrees to pay to Quick Doc, within a reasonable time after any such refund, an amount equal to the reasonable and customary value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid.
9.4 Assignment and Binding Effect. You may not sell, assign, transfer or otherwise convey any of your rights or delegate any of your duties under this Agreement.
9.5 Governing Law and Jurisdiction. This Agreement shall be governed by and construed in accordance with the laws of the State of North Carolina. All disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction in Forsyth County, North Carolina.
9.6 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.
9.7 Legal Significance. You acknowledge that this Agreement is a legal document and creates certain rights and responsibilities. You also acknowledges having had reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so, or have done so and is satisfied with the terms
and conditions of the Agreement. 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.
9.8 Notice. Any notice or other communication required or permitted to be given hereunder shall be in writing and shall be mailed by certified mail, return receipt requested, express courier, or overnight courier with prepaid, tracked delivery, to the addresses provided during enrollment, or handdelivered to the party to whom it is to be given. Any party may change such address by written notice to the other party. Any notice or other communication given by certified mail shall be deemed received, whether actually received or not, on the earlier of the date signed for by the recipient or that date which is three (3) business days after mailing, as evidenced by a mailing receipt obtained at the time of mailing. Express courier/overnight courier and hand delivery shall be deemed received when delivered to the addressed party. Notwithstanding anything herein to the contrary, if actual written notice is received, regardless of the means of transmittal, such notice shall be deemed to be acceptable and effective as proper notice under this Section 9.8.
10. Virtual Telehealth Services. All Virtual Telehealth Services offered to you through this agreement are provided by independent licensed physicians. We accept NO LIABILITY for any care provided by any provider using the Virtual Telehealth Services. Any incremental services, not outlined in Schedule C, provided by these independent licensed physicians my required additional cost and is the sole responsibility of the patient and or their legal guardian. We accept no liability of any kind with regard to these services. You agree to hold Quick Doc Partners, LLC, its director, executives, shareholders, employees, consultants, and agents harmless and free from any liability related to any Virtual Telehealth Services provided as part of this agreement.
Non-Clinical Services.
1. Same Day/Next Day Appointments. When you call or email Quick Doc prior to noon on a business day (Monday through Friday) to schedule an appointment, every reasonable effort shall be made to schedule an appointment with a Quick Doc provider on the same day. Depending on the nature of your medical condition or the Services requested, a Quick Doc provider will determine whether to schedule an appointment for (i) an in-person visit, (ii) a video-chat session, or (iii) a phone consultation. If you call or email Quick Doc after noon on a normal business day (Monday through Friday) to schedule such an appointment, every reasonable effort shall be made to schedule such appointment with a Quick Doc provider on the following business day (Monday through Friday), subject to a Quick Doc provider’s availability. In any event, however, Quick Doc shall make reasonable efforts to schedule appointments for you on the same day that the request is made.
2. Access. A Quick Doc provider will make reasonable efforts to be available by direct telephone access on a 6 days per week basis. Our current operating hours are Monday-Friday 8 AM ET to 5 PM ET and Saturday 9 AM ET to 2 PM ET. A Quick Doc provider may from time to time, due to illness, continuing medical education, days off, vacations, emergencies, or similar situations, not be available to provide Services. During a Quick Doc provider’s absence, your calls may be directed to a substitute medical provider qualified to provide the Services to Patient. Quick Doc will make reasonable efforts to arrange for such substitute coverage in a Quick Doc provider’s absence, but cannot guarantee such coverage. When feasible for your medical needs, a Quick Doc provider will make reasonable efforts to be available for “virtual visits” via phone, email, text, or video chat.
3. Email Access. You shall be provided with Quick Doc email address to which non-urgent communications can be addressed. A Quick Doc provider shall make reasonable efforts to respond to such communications in a timely manner. You understand and agree that you will never use email to attempt to access medical care in the event of an emergency, or any situation that you could reasonably expect may develop into an emergency.
Clinical Services. As a participant in the Program, you are entitled to access the primary care and preventive health services set forth here that a Quick Doc provider is permitted to perform under the laws of the State of North Carolina and that are consistent with his/her training and experience as a family medicine provider, unless a Quick Doc provider, in his/her medical judgment, determines that your medical condition warrants treatment from another health care provider. Quick Doc does not provide emergency services. You agree that if you have a medical emergency, you will call 911 or seek treatment at the nearest hospital emergency department.
Covered ServicesPrimary/Preventive Care (as deemed appropriate by your Quick Doc provider):
Incremental Services offered at Discounted Fees:
A Quick Doc provider may perform some blood draws and sample collection at his/her discretion, which may be sent to an outside lab to perform the test. At other times, you may be sent to qualified lab for sample collection. If your Quick Doc provider recommends a laboratory test or other service (such as radiology and pathology) which are not on the above “covered” list, they will discuss with you the additional costs and relevance to your care before proceeding and make every effort to guide you to the most cost-effective services in our area.
Non-Clinical Services.
While the services below are not offered by Quick Doc, your Quick Doc provider will assist you in finding the appropriate provider for the following medical conditions:
*Any services that result in a prescription for a controlled substance will require a higher service fee per office visit
THIS SERVICE IS NOT FOR EMERGENCIES AND IF THE MEMBER THINKS THEY ARE EXPERIENCING A MEDICAL EMERGENCY THEY SHOULD CALL 911 IMMEDIATELY.
Member will have access to a qualified medical care provider from your computer, smartphone, or tablet at no out of pocket cost (there are no deductibles, copays, coinsurance claims or bills) unless otherwise specified for services not covered under this agreement.
The eligible services are as follows:
Virtual Urgent Care Services
Virtual Mental Health Counseling Services
***It is important to note that controlled substances such as, but not limited to, pain medicine cannot be prescribed through Telehealth services.
Member will have online access to web based tools and resources that provide discounted pricing for the following healthcare services:
The available discounts will vary based on the service, supplies and or supplier from which they are purchased.
Any services not listed on this Schedule C are not included in the Capstone Health Network .
This Quick Doc Privacy Policy describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully.
Quick Doc is permitted by federal privacy laws to make use and disclosure of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination, and test results, diagnoses, treatment, and applying for future
care or treatment. It also includes billing documents for those services.
Examples of Uses of Your Health Information for Treatment Purposes are:
Example of Use of Your Health Information for Payment Purposes:
We submit requests for payment to your health insurance company. The health insurance company (or other business associate helping us obtain payment) requests information from us regarding medical care given. We will provide information to them about you and the care given.
Example of Use of Your Information for Health Care Operations:
We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol, and clinical guideline development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such
insurers or other business associates as necessary to obtain these services.
Use and Disclosure of PHI Without Your Authorization
Quick Doc is permitted to use PHI without your written authorization, or opportunity to object in certain situations, including:
Communication with Family
To a family member, other relative, or close personal friend, or other individual involved in your care if we obtain your verbal agreement to do so, or if we give you an opportunity to object to such a disclosure, and you do not raise an objection. We may also disclose health information to your family, relatives, or friends if we infer from the circumstances that you would not object. For example, we may assume you agree to our disclosure of your personal health information to your spouse when your spouse has called the ambulance for you. In situations where you are not capable of objecting (because you are not present or due to your incapacity or medical emergency), we may, in our professional judgment, determine that a disclosure to your family member, relative, or friend is in your best interest. In that situation, we will disclose only health information relevant to that person’s involvement in your care.
Notification
Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.
Workers Compensation
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.
Public Health
As authorized by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability; to report reactions to medications or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition.
Abuse & Neglect
We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.
Employers
We may release health information about you to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-related illness or
injury. In such circumstances, we will give you written notice of such release of information to your employers. Any other disclosures to your employer will be made only if you execute a specific authorization for the release of that information to your employer.
Correctional Institutions
If you are an inmate of a correctional institution, we may disclose to the institution or its agents the protected health information necessary for your health and the health and safety of other individuals.
Law Enforcement
We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecution, or to the extent an individual is in the custody of law enforcement.
Health Oversight
Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.
Judicial/Administrative Proceedings
We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your authorization, or as directed by a proper court order.
Serious Threat
To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.
For Specialized Governmental Functions
We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.
Coroners, Medical Examiners, and Funeral Directors
We may release health information to a coroner or medical examiner. This may be necessary, for example, o identify a deceased person or determine the cause of death. We may also release health information about patients to funeral directors as necessary for them to carry out their duties.
Other Uses
Any other use or disclosure of PHI, other than those listed above will only be made with your written authorization, (the authorization must specifically identify the information we seek to use or disclose, as well as when and how we seek to use or disclose it). You may revoke your authorization at any time, in writing, except to the extent that we have already used or disclosed medical information in reliance on
that authorization as previously provided in this Notice under “Your Health Information Rights.”
Your Health Information Rights
The health and billing records we maintain are the physical property of the Quick Doc. The
information in it, however, belongs to you. You have a right to:
Our Responsibilities
Quick Doc is required to:
Maintain the privacy of your health information as required by law;
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices
and to enact new provisions regarding the protected health information we maintain. If our information
practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling
and requesting a copy of our “Notice” or by visiting our office and picking up a copy.
To Request Information or File a Complaint
If you have questions, would like additional information, report a problem regarding the handling of your
information, or if you believe your privacy rights have been violated, you may file a written complaint at our
office by delivering the written complaint to:
HIPAA Privacy and Security Officer
Alandria Hawkins
3734 Reynolda Road
Winston-Salem, NC 27106
You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services,
whose street address and e-mail address is: Office for Civil Rights – U.S. Department of Health and Human
Services – 200 Independence Avenue S.W. – Room 509F, HHH Building – Washington, D.C. 20201.
• We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health
and Human Services (HHS) as a condition of receiving treatment from the clinic.
• We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and
Human Services