67 S. Higley Rd., Suite 104 Gilbert, AZ 85296
Family Tree Eye Care, LLC (“the Practice) is a Direct Primary Care Optometrist practice (“DPC”), which delivers eye care services at 67 South Higley Road, Gilbert, AZ 85296 US. In exchange for certain fees, the practice agrees to provide you with the services described in Appendix A on terms and conditions contained in Appendix A of this agreement (“Agreement”).
1. Patient. In this Agreement, “Patient” means the person(s) for whom the Optometrist shall provide care, and who have signed this agreement or are listed under Appendix B, which is a part of this agreement.
2. Services. In this Agreement, “Services”, means the collection of services, offered to you by Family Tree Eye Care in this Agreement. These Services are listed in Appendix A(1), which is attached and a part of this Agreement.
3. NOTICE: THIS RETAINER AGREEMENT DOES NOT CONSTITUTE INSURANCE, IS NOT AN EYE CARE PLAN THAT PROVIDES HEALTH INSURANCE COVERAGE FOR PURPOSES OF THE FEDERAL PATIENT PROTECTION AND AFFORDABLE CARE ACT AND COVERS ONLY LIMITED, ROUTINE HEALTH CARE SERVICES AS DESIGNATED IN THIS
4. Term. This Agreement is for the term of one (1) year, commencing on the date this agreement is signed.
5. Renewal. This agreement is automatically renewed on the anniversary date of this agreement, contingent upon Patient’s payment of the annual membership fee within ten days of the renewal date. Payment is received upon Patient’s verbal or written authorization to charge the credit or debit card on file with the Practice as set forth in Appendix B.
6. Termination. Either party may cancel this agreement with thirty (30) days written notice. If Patient cancels, there be no refund of the annual membership fee except as provided in Paragraph 7(c) below. If the Practice cancels it will refund that portion of the annual membership fee not applied to services already provided during the membership term.
7. Payments and Refunds – Amount and Methods. In exchange for the Services (see Appendix A(1)), You agree to pay Family Tree Eye Care, an annual fee in the amount that appears in Appendix C, which is attached and is part of this Agreement.
a) The specified annual fee must be paid in full after signing the agreement before Patient is eligible to receive services and is not retroactive. The agreement is renewed annually as set forth in Paragraph 5.
b) The Parties agree that the required method of annual payment shall be by debit, credit card, check, or cash (US dollars).
c) Annual membership fee is non-refundable. This Agreement may be canceled by either party before the Agreement ends but Family Tree Eye Care is not obligated to refund any fee but may consider these few exceptions as follows:
1)Patient moves out of state or distance to travel to 67 South Higley Road Gilbert, AZ 85296 US is greater than four hours commute by motorized vehicle without receiving any single or multiple service or benefit.
2) Patient death without receiving any single or multiple service or benefit.
8. This Is Not Health Insurance. Your signature on this clause of the Agreement acknowledges your understanding that this Agreement is not an insurance plan or a substitute for health insurance. You understand that this Agreement does not replace any existing or future health insurance or health plan coverage that you may carry. The Agreement does not include hospital services, eye care specialists’ services, or any services not personally provided by Family Tree Eye Care or its employees. You acknowledge that the practice has advised you to obtain or keep in full force, health insurance that will cover you for healthcare not personally delivered by the practice, and for hospitalizations and catastrophic events.
9. Communications. The Patient acknowledges that although Family Tree Eye Care shall comply with HIPAA privacy requirements, communications with the Optometrist using e-mail, facsimile, video chat, cell phone, texting, and other forms of electronic communication can never be absolutely guaranteed to be secure or confidential methods of communications. As such, Patient expressly waives the Optometrist’s obligation to guarantee confidentiality with respect to the above means of communication. Patient further acknowledges that all such communications may become a part of the eye care record.
By providing an e-mail address on the attached Appendix B during enrollment, the Patient authorizes Family Tree Eye Care, and its owners, employees and representatives to communicate with him/her by e-mail regarding the patient’s “protected health information” (PHI).1 The Patient further 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 the Family Tree Eye Care will make all reasonable efforts to keep e-mail communications confidential and secure, neither the practice, nor the Optometrist can assure or guarantee the absolute confidentiality of e-mail communications;
(c) At the discretion of the Family Tree Eye Care, e-mail communications may be made a part of Patient’s permanent eye care record; and,
(d) You understand and agree that e-mail is not an appropriate means of communication in an emergency, for time-sensitive problems, or for disclosing sensitive information. In an emergency, or a situation that you could reasonably expect to develop into an emergency, you understand and agree to call 911 or the nearest emergency room, and follow the directions of emergency personnel.
(e) Email Usage. The Family Tree Eye Care team checks e-mail frequently on weekdays, during business hours. If you do not receive a response to an e-mail message by the next business day, you agree that you will contact Family Tree Eye Care by telephone or other means.
(f) Technical Failure. Neither Family Tree Eye Care, nor the Optometrist will be liable for any loss, injury, or expense arising from a delay in responding to Patient, when that delay is caused by technical failure. Examples of technical failures (i) failures caused by an internet service provider, (ii) power outages, (iii) failure of electronic messaging software, or e-mail provider (iv) 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 which is unauthorized by the practice; or (v) patient failure to comply with the guidelines for use of e-mail described in this Agreement.
10. Optometrist Absence. From time to time, due to vacations, illness, or personal emergency, the Optometrist may be temporarily unavailable to provide the services referred to above in this paragraph one. In the event of the Optometrist’s absence during usual clinic hours, Patients will be given the name and telephone number of an appropriate provider for the Patient to contact.
11. Change of Law. If there is a change of any relevant law, regulation or rule, federal, state or local, which affects the terms of this Agreement, the parties agree to amend this Agreement to comply with the law.
12. Severability. If any part of this Agreement is considered legally invalid or unenforceable by a court of competent jurisdiction, that part will be amended to the extent necessary to be enforceable, and the remainder of the contract will stay in force as originally written.
13. Reimbursement for Services Rendered. If this Agreement is held to be invalid for any reason, and the practice is required to refund fees paid by you, you agree to pay the practice an amount equal to the fair market of the eye care services you received during the time period for which the refunded fees were paid.
14. Amendment. No amendment of this Agreement shall be binding on a party unless it is in writing and signed by all the parties. Except for amendments made in compliance with Section 12 above.
15. Assignment. This Agreement, and any rights you may have under it, may not be assigned or transferred by you.
16. Legal Significance. You acknowledge that this Agreement is a legal document and gives the parties certain rights and responsibilities. You also acknowledge that you have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.
17. Miscellaneous. This Agreement shall be construed without regard to any rules requiring that it be construed against the party who drafted the Agreement. The captions in this Agreement are only for the sake of convenience and have no legal meaning.
18. Entire Agreement. This Agreement contains the entire agreement between the parties and replaces any earlier understandings and agreements whether they are written or oral.
19. No Waiver. In order to allow for the flexibility of certain terms of the Agreement, each party agrees that they may choose to delay or not to enforce the other party’s requirement or duty under this agreement (for example notice periods, payment terms, etc.). Doing so will not constitute a waiver of that duty or responsibility. The party will have the right to enforce such terms again at any time.
20. Jurisdiction. This agreement shall be governed and construed under the laws of the State of Arizona. All disputes arising out of this agreement shall be resolved through arbitration in Maricopa County, Arizona.
21. Service. All written notices are deemed served if sent to the address of the party written above or appearing in Appendix B by first class U.S. mail.
APPENDIX A: SERVICES
Eye Care Services. Eye Care & medical services under this agreement are those eye care services that the Optometrist is permitted to perform under the laws of the State of Arizona, are consistent with Optometrist’s training and experience, are usual and customary for an Optometrist to provide, and include the following:
• Comprehensive eye examination with $25 copay including dilation
• Ultra wide digital retinal imaging discounted to $25
• Standard contact lens medical evaluation $60 copay
• Specialty contact lens medical evaluation $120 copay
• $100 frame benefit with each complete pair purchased
• Access to exclusive pricing on usual and customary material fees
• Poly-carbonate lenses are standard
• Eyeglasses adjustments for glasses purchased in office
• Eyeglass repairs for glasses purchased in office
• Nose-pad replacements for glasses purchased in office
• Eyeglass cleaning for glasses purchased in office
• 1-year scratch warranty on lenses
• 1-year frame warranty for manufacturer defects
Contact lens Benefits:
• 10% discount on all contact lenses
• Emergency contact lenses if dangerously low
• Replacement of defective contact lenses
• Exchange unopened contact lens boxes when purchased in office
• Free direct shipping on purchase of annual supply of contact lenses
Non-eye care, Personalized Services. Family Tree Eye Care shall also provide patient with the following non-eye care services (“Non-eye care Services”), which are complementary to our members in the course of care:
a. After Hours Access. Patient shall have telephone access to the Optometrist and/or the practice answering service.
b. E-Mail Access. Patient shall be given the practice’s e-mail address to which non-urgent communications can be addressed. Such communications shall be dealt with by the Optometrist or Team member of Family Tree Eye Care in a timely manner. Patient understands and agrees that email and the internet should never be used to access eye 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 the Optometrist 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. Minimal Wait Appointments. Reasonable effort shall be made to assure that patient is seen by the Optometrist immediately upon arriving for a scheduled office visit or after only a minimal wait.
d. Specialists Coordination. Practice and Optometrist shall coordinate with 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 specialist fees or fees due to any eye care professional other than Family Tree Eye Care.
APPENDIX B: PATIENT ENROLLMENT AGREEMENT FORM
Annual fees as set out in Appendix C shall apply to the following Patient(s), who by signing below, or legal guardian or guarantor signing below agree to the terms and conditions of the Family Tree Eye Care Agreement Form.
List of family members included in this agreement:
1. ____________________________________6. ____________________________________
2. ____________________________________7. ____________________________________
3. ____________________________________8. ____________________________________
4. ____________________________________9. ____________________________________
5. ____________________________________10. ___________________________________
*All patients must have a credit or debit card on file to cover the cost of membership & any incidentals not covered under the Agreement.
I certify that I have read, understand, and agree to the terms set forth in this
Agreement Form. I further certify that I have the option to receive a copy of this form.
Individual = $120/YearFamily 4 = $365/YearFamily 7 = $560/Year
Family 2 = $200/YearFamily 5 = $450/YearFamily 8 = $640/Year
Family 3 = $275/YearFamily 6 =$500/YearFamily 9 = $720/Year
Click here to download