MEMBERSHIP AGREEMENTS

The health plan includes a prescription discount card, discounts on Dental, Vision, DME, Teladoc, Road Service Assistance, and Patient Advocacy through inclusion of your membership in the Patient/Physician Cooperative. I (we) agree to abide by the terms of the PPC membership as printed in the Membership Booklet.  I (we) authorize the employer above to honor and pay these monthly charges. I (we) understand that in order to cancel these payments, I (we) must provide written notice to Patient/Physician Cooperatives and Group Employee Benefit Plan 30 days before the next scheduled payment. Until such notice is received, I (we) agree that you shall be fully protected in honoring any payroll deductions, bank charges or drafts.

Primary Care Services Agreement

I agree to a one year contract with my selected Provider for access to primary care services. I understand any request to change providers prior to the end of my 12 month contract must be submitted in writing to be reviewed & approved by Member Services.

Imaging Services Agreement

I agree to a one year contract with my selected Provider for access to Imaging Services. I understand any request to change providers prior to the end of my12 month contract must be submitted in writing to be reviewed & approved by Member Services.

Lab Services Agreement

I agree to a one year contract with my selected Provider for access to Lab Services. I understand any request to change providers prior to the end of my12 month contract must be submitted in writing to be reviewed & approved by Member Services.

I understand that the health benefits under this Employee ERISA Trust Plan will become effective on the effective date shown in the Schedule of Benefits of the Certificate to be issued to me by the Trust. I declare that to the best of my knowledge and belief, all of the information contained in the enrollment form is true and correct and that no material information has been withheld or omitted. WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application/enrollment form containing any false, incomplete, or misleading information may be guilty of a crime and may be subject to fines and confinement in prison.

Membership begins on the 1st of the month following enrollment.

Payment Terms:

Payroll Deduction, credit card, debit card, cash or check are accepted for the initial payment. Monthly fees must be paid by payroll deduction, credit card, debit card, or draft from checking or savings account. Payroll deductions are made at the time of the employer’s schedule payroll distributions. All drafts or credit / debit charges will be made on the 15th of the month prior to the month of service. Any payments or drafts that are refused by the bank or credit card will be considered delinquent. And any bank charges for an overdraft will be the responsibility of the member. All fees must be paid on the due date each month to remain current and an active member. When membership fees that are 30 days past due the benefits automatically terminate and will be reinstated only after the have been paid in full, past and current.
Membership is for 12 month renewable terms. Members are responsible for fees for one full year at a time even though they may pay on a monthly basis.
Member agrees to the above terms and conditions.
I agree to the terms of the membership agreement

HIPAA AUTHORIZATION STATEMENT OF INTENT

It is my understanding that Congress passed a law entitled the Health Insurance Portability and Accountability Act (“HIPAA”) that limits disclosure of my protected medical information. This authorization is being signed because it is crucial that my medical providers readily give my protected medical information to the persons designated in this authorization in order to allow me the advantage of being able to discuss and obtain advice from my family and/or friends.
Therefore, pursuant to 45 CFR 164.501(a)(1)(iv) a covered entity (being a health care provider as defined by HIPAA) is permitted to disclose protected health information pursuant to and in compliance with this valid authorization under 45 CFR Sec. 164.508.

AUTHORIZATION

I, {name}, an individual, hereby authorize all covered entities as defined in HIPAA, including but not limited to a doctor, (including but not limited to a physician, podiatrist, chiropractor, or osteopath,) psychiatrist, psychologist, dentist, therapist, nurse, hospitals, clinics, pharmacy, laboratory, ambulance service, assisted living facility, residential care facility, bed and board facility, nursing home, medical insurance company or any other health care provider or affiliate, to disclose the following information:
All health care information, reports and/or records concerning my medical history, condition, diagnosis, testing, prognosis, treatment, billing information and identity of health care providers, whether past, present or future and any other information which is in any way related to my healthcare. Additionally, this disclosure shall include the ability to ask questions and discuss this protected medical information with the person or entity who has possession of the protected medical information even if I am fully competent to ask questions and discuss this matter at the time. It is my intention to give a full authorization to ANY protected medical information to the following authorized entity, its affiliates, employees and agents:

Senior Patient Association 866-549-4199 dba

Patient/Physician Cooperatives PO Box 1838

Splendora, TX 77372

TERMINATION

This authorization shall terminate on the first to occur of: (1) two years following my death or (2) upon my written revocation actually received by the covered entity. Proof of receipt of my written revocation may be by certified mail, registered mail, facsimile, or any other receipt evidencing actual receipt by the covered entity. This revocation shall be effective upon the actual receipt of the notice by the covered entity except to the extent that the covered entity has taken action in reliance on it. This authorization is not affected by my subsequent disability or incapacity.

RE-DISCLOSURE

By signing this Authorization, I acknowledge that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the person or persons whose name(s) is/are written above, and the information once disclosed will no longer be protected by the rules created in HIPAA. No covered entity shall require my authorized persons to indemnify the covered entity or agree to perform any act in order for the covered entity to comply with this authorization.
INSTRUCTIONS TO MY AUTHORIZED PERSONS
My authorized persons shall have the right to bring a legal action in any applicable form against any covered entity that refuses to recognize and accept this authorization for the purposes I have expressed. Additionally, my authorized persons are authorized to sign any documents that the authorized persons deem appropriate to obtain the protected medical information.

VALID DOCUMENT

A copy or facsimile of this original authorization shall be accepted as though it were an original document.

WAIVER AND RELEASE

I hereby release any covered entity that acts in reliance on this authorization from any liability that may accrue from releasing my protected medical information and for any actions taken by my authorized persons.