Wellness Contract for Medical Services
Medicare Patient Contract
This contract is between Pronto Care, hereafter referred to as “Pronto Care” and_____________________________, hereafter referred to as “patient.” This contract established an agreement for Pronto Care to provide certain medical services to the patient. The terms of this agreement are detailed below:
Covered Medical Services
Pronto Care agrees to provide “Covered Medical Services” to the patient. Covered Medical Services are designed to promote the wellness of the patient through a program of periodic examinations, preventative care, and medical information. Covered Medical Services are detailed in Exhibit A and include the following.
- Office visits for routine checkups consisting of one (1) visit per month as medically needed;
- Baseline Cardio vascular testing including stress test (Treadmill)
- Echocardiogram, if medically indicated;
- Vascular studies, if medically indicated, including Carotid Doppler, Arterial Doppler, and Venous Doppler of the lower extremities, Arterial Doppler of the abdominal aorta, 24 hour holter monitor testing;
- Baseline and as needed electrocardiogram testing;
- When indicated, interrogation of cardiac device, (whether pacemaker or defibrillator);
- Free annual wellness blood work
- When available, free trial samples of medication for blood pressure and lipid lowering therapy;
- Make appropriate referrals where indicated
The covered medical services are part of Pronto Care’s Wellness and Preventative Medicine Plan. Under the Wellness and Preventative Medicine Plan, the covered medical services are provided to the patient on an annual fixed fee basis. Under the plan, the following terms apply:
- No denial for coverage under the plan for pre-existing conditions.
- No copayments apply to the costs for services
- No pre-authorization is required
- No referrals are necessary
- The plan has open enrollment at any time during the year
- Referrals to specialists will be made as appropriate and as indicated
- Services will be provided during regular business hours of Pronto Care
Medical Services EXCLUDED:
Charges for any test, procedures, services or vaccinations not listed in Exhibit A are the responsibility of the patient. Professional services that are not covered by this contract may be provided to the patient by Pronto Care through appropriate separate financial arrangements.
This contract does not cover or include hospital admission(s) or treatment(s). This contract also does not cover urgent services or emergency services requiring hospitalization, or services of other physicians or health care providers arising out of the referral of a medical issue to a specialist or other health care provider.
Costs for Services:
The costs for services provided under this contract is an annual fee of $810.00 which annual fee may be paid in full in advance. The fee may be paid in advance in monthly installments of $75.00 per month. Monthly fees shall be paid in advance by the 1st day of each month. The annual fee or the monthly fee is the base charge for the providing of Covered Medical Services by Pronto Care and must be paid annually or monthly, as applicable, in order for the patient to be eligible to receive the Covered Medical Services under this contract from Pronto Care.
This contract shall be in effect for one year from the date of its execution. Full payment of the annual fee for services or payment of the monthly fee during the term of the contract guarantees this contract for one (1) year from the date of execution of the contract.
The failure to pay the annual fee or the failure to pay the monthly fee, when due, will terminate this contract without notice or demand. This contract is renewable annually with the mutual consent of Pronto Care and the patient. Pronto Care reserves the right to change the annual fee or the monthly installment for service upon renewal. The patient may cancel this contract at any time during the year by giving thirty (30) days written notice to Pronto Care. In the event of cancellation, the patient’s fee is non–refundable.
The patient has read this contract and agrees to the terms specified within:
Patient Name __________________________________________ Date _______________
Pronto Care __________________________________________ Date _______________
Toll Free: 1 (877) 373- 5346
2204 Ashley Oaks Circle, Suite 102
Wesley Chapel, FL. 33543
Phone: (352) 592-4938
Fax: (352) 592-4941