Business Intake Form

DIRECT HEALTH CARE AGREEMENT

Oak Concierge Medicine

Welcome to Oak Concierge Medicine! Thank you for trusting us with your care. We look forward to partnering with you to optimize your health and well-being. This Agreement outlines how we will work together. By signing this Agreement, remitting payment for your membership fee, or accepting an in-person or virtual appointment, you agree to the following:

This Direct Health Care Agreement (“Agreement”) is between the undersigned individual (“You,” “Patient,” or “Member”) and Oak Concierge Medicine (“Practice,” “Us,” or “We”). The Practice provides ongoing primary care services to its Members under a direct-pay, membership-based model (“DPC”). In exchange for the fees described in this Agreement, the Practice agrees to provide the Services described below under the stated terms and conditions.

1. Services

“Services” refers to the medical and non-medical services listed in Appendix A, which is incorporated by reference. These Services are available to you as part of your membership subject to the terms of this Agreement.

2. Patient Definition

“You,” “Patient,” “Member,” or “Yours” means the individual who receives care from the Practice and who signs this Agreement.

3. Term

This Agreement begins on the date it is fully executed and continues for one (1) year. It will automatically renew for successive one-year terms on each anniversary date unless terminated under Section 4.

4. Termination
A. Termination by You

You may terminate your membership at any time, without cause, by giving thirty (30) days’ written notice.

Membership requires a six (6) month minimum commitment.

If you terminate before the 6-month minimum, you will be charged a $150 early termination fee at the time of cancellation.

If you terminate after 6 months, the fee does not apply.

Any prepaid, unused membership fees will be prorated and refunded. Re-enrollment requires paying the Enrollment Fee again.

B. Immediate Termination by You for Cause

You may terminate immediately if the Practice materially breaches this Agreement.

C. Termination by the Practice

The Practice may terminate this Agreement and your membership with thirty (30) days’ written notice, or any additional time reasonably needed to transition your care.

D. Immediate Termination by the Practice

Immediate termination may occur if:

i. Failure to pay fees when due
ii. Failure to sign required documentation
iii. Failure to follow treatment recommendations
iv. Disruptive, abusive, threatening, or unsafe behavior toward staff or patients
v. The Practice ceases operation

5. Payments & Refunds
A. Membership Fees

You agree to pay the monthly membership fee listed in Appendix B. The Practice may change fees with 30 days’ written notice.

B. Enrollment Fee

A one-time, non-refundable Enrollment Fee of $150 is due upon signing.

C. Monthly Billing

Membership Fees are due on the first business day of each month.

D. Payment Method

Automatic debit or credit card payment is required and must remain on file.

E. Refunds

If this Agreement is terminated, any unused portion of Membership Fees will be refunded on a prorated basis.

6. Non-Participation in Health Insurance

Oak Concierge Medicine does not participate with any insurance plans, HMOs, Medicare Advantage plans, Medicaid, or other payors.

The Practice:

Will not bill third-party payors

Makes no guarantees regarding reimbursement

Does not currently “opt out” of Medicare

Because the provider has not opted out of Medicare, the Practice cannot provide Medicare-covered services for cash payment to Medicare beneficiaries.

If you become eligible for Medicare, you must notify the Practice immediately.

7. Disclaimer: Not Health Insurance

This Agreement is not insurance and does not replace health insurance.

The Agreement does not cover:

Hospital services

Emergency care

Medications

Specialist visits

Laboratory testing

Imaging

Pathology

Any service not directly delivered by the Practice

The Practice recommends maintaining health insurance for catastrophic and specialty care.

8. Communications & Privacy
A. Electronic Communication Risks

The Practice may communicate via email, text, electronic messaging, telehealth platforms, and phone. While safeguards are used, absolute confidentiality cannot be guaranteed.

By signing this Agreement, you acknowledge these risks and consent to communication through these channels unless you decline a specific method.

B. Limited Disclosure

The Practice will not disclose PHI except as permitted for treatment, payment operations, or unless required by law.

C. HIPAA & Notice of Privacy Practices

You acknowledge receipt of the Practice’s Notice of Privacy Practices and authorize the Practice to use and disclose your PHI as described therein.

9. Email & Text Messaging Usage

By providing your email and/or cell number:

You authorize communication containing PHI

You understand these are not secure channels

You acknowledge they are not suitable for emergencies

For emergencies, you agree to call 911 or seek immediate emergency care.

10. Technical Failure Disclaimer

The Practice is not responsible for delays or failures caused by:

Internet or phone outages

Power loss

Software malfunction

Device failure

Unauthorized interception

Your failure to follow communication guidelines

11. Provider Absence

If the provider is unavailable due to illness, vacation, or emergency:

The Practice will notify patients when possible

Non-urgent appointments will be rescheduled

Patients must seek urgent care or emergency services when necessary

The Practice is not responsible for outside charges, which may be submitted to insurance by the patient

12. Dispute Resolution

Both parties agree not to publish false, inaccurate, or disparaging statements. Any complaints must follow this process:

A. Discuss with the provider
B. Provider responds
C. Mutual discussion to resolve
D. If unresolved → mediation → binding arbitration

Small claims brought by the Practice are exempt.

13. Non-Disparagement

You agree not to make false, misleading, or disparaging statements about the Practice or its staff.

14–25. Standard Legal Provisions

These sections include:

Change of Law

Severability

Amendment

Assignment

Legal Significance

Miscellaneous

Entire Agreement

No Waiver

Non-Discrimination

Governing Law (Florida) & Binding Arbitration

Required Written Notice Address

Survival of Terms

These remain unchanged from your draft, but I can polish them further upon request.

14. Change of Law

If any federal, state, or local law, regulation, or rule is enacted or amended in a manner that materially affects this Agreement or the services provided under it, the parties agree to amend this Agreement only to the extent necessary to comply with such change in law. All other terms shall remain in full force and effect.

15. Severability

If any provision of this Agreement is determined by a court or arbitrator of competent jurisdiction to be invalid, illegal, or unenforceable, that provision shall be modified to the minimum extent necessary to make it enforceable, and the remaining provisions of this Agreement shall continue in full force and effect.

16. Amendment

Except as otherwise provided herein, this Agreement may be amended only by a written document signed by both the Patient and the Practice. No oral statements or prior written communications shall modify the terms of this Agreement.

17. Assignment

Neither this Agreement nor any rights or obligations arising under it may be assigned or transferred by either party without the prior written consent of the other party, except that the Practice may assign this Agreement in connection with a merger, reorganization, or sale of substantially all of its assets.

18. Legal Significance

The Patient acknowledges that this Agreement is a legally binding contract that creates rights and obligations for both parties. The Patient affirms that they are not experiencing a medical emergency at the time of execution and have had adequate opportunity to review this Agreement, seek legal advice if desired, and ask questions before agreeing to its terms.

19. Miscellaneous

This Agreement shall be interpreted without regard to any rule requiring construction against the drafting party. Section headings are provided for convenience only and have no legal or contractual effect.

20. Entire Agreement

This Agreement, together with its Appendices and referenced policies, constitutes the entire agreement between the parties and supersedes all prior or contemporaneous agreements, representations, or understandings, whether written or oral, relating to the subject matter herein.

21. No Waiver

The failure of either party to enforce any right or provision of this Agreement shall not constitute a waiver of that right or provision, nor shall it limit that party’s ability to enforce the same or any other provision at a later time.

22. Non-Discrimination

The Practice shall not discriminate against the Patient on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, ancestry, disability, medical condition, genetic information, marital status, citizenship, primary language, or any other status protected by applicable law. The Practice reserves the right to accept or decline patients based on its clinical capacity to appropriately manage a patient’s primary care needs.

23. Governing Law & Binding Arbitration

This Agreement shall be governed by and construed in accordance with the laws of the State of Florida, without regard to conflict of law principles. Any dispute arising out of or relating to this Agreement shall be resolved by binding arbitration administered by an arbitration service selected by the Practice. Judgment on the arbitration award may be entered in any court of competent jurisdiction. Small claims actions brought by the Practice are exempt from this arbitration requirement. The costs of arbitration shall be borne equally by the parties unless otherwise required by law.

24. Notice

Any written notice required under this Agreement may be delivered by electronic mail to the email address provided by the receiving party or by first-class U.S. Mail. Notices to the Practice shall be sent to:

Oak Concierge Medicine
817 NW 56th Terrace, Suite B
Gainesville, Florida 32605

Notices to the Patient shall be sent to the address or email provided by the Patient.

25. Survival

Any provisions of this Agreement that by their nature are intended to survive termination or expiration of this Agreement shall survive, including but not limited to provisions regarding payment obligations, dispute resolution, non-disparagement, privacy, and governing law.

Monthly membership payments are billed automatically on a recurring basis beginning on the date of enrollment. By enrolling in membership, You authorize Oak Concierge Medicine to charge the monthly membership fee to the payment method provided through Stripe, the Practice’s secure third-party payment processor.

Payments will be processed monthly on the enrollment date unless otherwise stated in writing. You agree to maintain a valid payment method on file at all times. If a payment is declined, returned, or fails to process, the Practice may suspend services until payment is successfully received.

All payment information is processed and stored securely by Stripe. Oak Concierge Medicine does not store full credit card or bank account information.

I acknowledge that I am the primary account holder and am financially responsible for all membership fees, charges, and services provided to any family members enrolled under my account, including minor dependents.