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Review and Sign Membership Agreement

Membership:

A Membership is required to become a patient of Wave Concierge and Internal Medicine of Boynton Beach. This membership fee is not covered by insurance and is the patient’s choice.

Insurance:

1. All office visits (including audio and/or video telehealth visits) will be filed to the patient’s insurance and processed according to the patient’s policy, benefits, and terms.
2. The initial 60-minute and subsequent annual comprehensive consultation and physical are not billed to insurance. However, any other services provided during these comprehensive visits (such as but not limited to vaccines, EKG, MRI, X-rays, ultrasounds) will be billed to the patient’s insurance.
3. Any co-pay or patient portion remaining after insurance adjustment will be the responsibility of the patient.

When Membership begins:

1. Membership begins once the Membership Agreement is completed by the patient and received by Wave Concierge and Internal Medicine of Boynton Beach.
2. Records from previous and current providers will be obtained and reviewed by the Doctor, who may request lab work.
3. The initial 60-minute comprehensive consultation and physical will occur once these results are obtained.
4. While awaiting the initial 60-minute visit, patients may contact the office for assistance or any urgent visit needs.

To begin your Membership with Wave Concierge and Internal Medicine of Boynton Beach, the following items are required:

1. Membership Agreement: Complete the agreement in its entirety to provide insurance, demographic information, and payment method. It outlines the benefits and terms of your membership.
2. Notice of Privacy Practices: Review how your medical information may be used and disclosed at https://waveconcierge.com/hippa-policy/.
3. Authorization to Obtain, Release, or Review Protected Health Information: Sign this form to allow the Doctor to review your medical history by obtaining records from current and previous physicians/facilities.
4. Physician Facility Records Request List: Provide detailed information about current and previous providers and facilities for record requests.

Terms and Conditions:

This Membership Agreement (“Agreement”) specifies the terms and conditions under which you, the undersigned member (“Member”), will be enrolled with Wave Concierge and Internal Medicine of Boynton Beach (the “Program”). This Agreement becomes effective on the date set forth by Wave Concierge and Gerardo Quinonez, MD, PA // DBA: Internal Medicine of Boynton Beach, located at 8190 Jog Rd. Suite 100, Boynton Beach, FL 33472 (“Effective Date”).

1. Personalized Primary Care Benefits and Services:

The Program provides the following amenities (“Amenities”) to Members:

1. House Calls from Doctor and Staff to your home and/or residence. (EXECUTIVE PLANS ONLY)
2. In-Home Diagnostics as possible. (EXECUTIVE PLANS ONLY)
3. Direct access to your doctor; telemedicine or NP visits available if the doctor is away.
4. 24/7 direct access to the physician.
5. Individual and couple plans.
6. Same day/next day urgent/emergency appointments.
7. Fitness counseling if required.
8. Enhanced office hours.
9. Same or next day in-house imaging (X-ray, ultrasound, MRI).
10. Delray Hospital admissions under concierge doctor.
11. Referral coordination and scheduling if requested.
12. Preventative care focus.
13. 60-minute comprehensive consultation and physical.
14. 1-hour annual physical examination.
15. 30 minutes of personal care for each appointment.
16. Phone/fax/web access.
17. Cell, text, and video conferencing with the doctor.
18. Concierge liaison.
19. Complimentary IV vitamin infusions per year. (TWO (2) FOR CONCIERGE PLANS, FOUR (4) FOR EXECUTIVE PLANS)
20. Complimentary aesthetic facials per year. (TWO (2) FOR CONCIERGE PLANS, FOUR (4) FOR EXECUTIVE PLANS)
21. For detailed benefits, visit https://WaveConcierge.com.

2. Membership Fee:

Members will pay a membership fee to Wave Concierge on behalf of Internal Medicine of Boynton Beach. A valid credit card or bank account info must be provided and kept on file. The fee will process as follows:

1. For 6-month membership: Fee processes every 6 months.
2. For 12-month membership: Fee processes every 12 months.

3. Member Billing and Payment Information:

Payment information will be collected along with the signing of this Membership Agreement.

4. Refund Policy:

1. Wave Concierge and Internal Medicine of Boynton Beach are dedicated to delivering exceptional and highly personalized medical care to our patients. The nature of our services requires a significant investment of time, effort, and expertise from our medical professionals, especially our concierge doctors. This investment begins from the moment a patient enrolls in our membership program and continues throughout their care.
2. Initial Consultations and Personalized Care Plans: Upon enrolling, your concierge doctor undertakes a comprehensive review of your medical history, which includes obtaining and analyzing medical records from previous providers, coordinating with various healthcare facilities, and conducting detailed assessments to understand your unique health needs. This initial phase involves meticulous attention to detail and substantial time commitment to ensure that every aspect of your health is thoroughly evaluated.
3. Comprehensive Medical Assessments: The initial 60-minute comprehensive consultation and physical examination are designed to establish a baseline for your ongoing care. This process involves in-depth diagnostic procedures, personalized health evaluations, and the formulation of a tailored healthcare plan. The doctor’s dedication to this phase is crucial in setting the foundation for effective and continuous medical care.
4. Ongoing Personalized Care: Throughout the membership, your concierge doctor provides continuous, personalized care, which includes regular follow-ups, preventive health measures, and immediate response to any urgent health concerns. The commitment to offering 24/7 access, same day/next day appointments, and personalized communication channels underscores the extensive effort invested in maintaining a high standard of care.
5. Refund Policy: Due to the significant initial and ongoing commitment of time, expertise, and resources required to provide this level of care, refunds are generally not offered once services have been rendered. This policy reflects the substantial preliminary work and continuous attention dedicated to each patient’s health and well-being.
6. Exceptional Circumstances: In rare and exceptional circumstances, such as the death of a member, a refund may be considered. If deemed appropriate, refunds will be processed with a 25% cancellation fee based on the total membership price. This fee accounts for the extensive initial work and dedication the doctor commits to each patient, including comprehensive medical assessments, detailed analyses, and personalized care planning.
7. Prorated Refunds: Should a refund be warranted under exceptional circumstances, the amount will be prorated to reflect the unused portion of the membership, minus the 25% cancellation fee. This ensures that while patients are fairly compensated for the unused portion of their membership, the significant time and effort already invested by the medical team are also duly acknowledged.
8. By engaging with the services of Wave Concierge and Internal Medicine of Boynton Beach, you acknowledge and agree to this refund policy, which is designed to sustain the exceptional quality of personalized care we are known for.

5. Termination:

1. The membership fee covers the defined period according to the chosen plan listed above.
2. Failure to pay the renewal fee on the anniversary of the Effective Date will result in termination of your membership.
3. You may terminate your participation at any time upon 30 days prior written notice to Wave Concierge and Internal Medicine of Boynton Beach. No refunds for unused portions except in rare circumstances.
4. Wave Concierge and Internal Medicine of Boynton Beach may terminate this Agreement at any time with 30 days written notice to you, providing a prorated refund.

6. Medical Care Services Excluded from Membership Fee:

The membership fees cover only the defined Amenities and the annual comprehensive physical examination and preventive healthcare plan visit. Except for your physical examination and preventative visit, you and/or your insurer will be financially responsible for all other healthcare and medical services.

7. Copayments and Deductibles:

The membership fee does not affect the co-payments, co-insurance, or deductibles required by your health insurance. You are responsible for any co-payments, co-insurance, or deductible amounts required by your insurer.

8. E-mail Communications; Privacy:

E-mail is not a secure medium for sending and receiving potentially sensitive personal health information. Although Wave Concierge and Internal Medicine of Boynton Beach will take steps to keep communications confidential and secure, the confidentiality of e-mail communications cannot be assured or guaranteed. E-mail is not a good medium for urgent or time-sensitive communications. At the discretion of Wave Concierge and Internal Medicine of Boynton Beach, or as required by law, e-mail communications may become part of your permanent medical record.

9. Consent:

Complete and sign the Consent section below.

10. Entire Agreement:

This Agreement constitutes the entire agreement between the parties. There are no promises or representations except as set forth herein.

11. Notices:

Any communication required or permitted under this Agreement shall be in writing and sent via certified mail, return receipt requested, or hand delivery to the addresses set forth herein. Any change in address shall be communicated accordingly.

12. Governing Law:

This Agreement shall be governed by the laws of the State of Florida. Each party agrees to submit to the personal jurisdiction and venue of the state and federal courts in Palm Beach County, Florida.

13. Amendments and Waivers:

This Agreement may only be amended or modified by written agreement of both parties. No waiver of any provision shall be valid unless in writing and signed by the party against whom the waiver is sought. One or more waivers shall not be construed as a waiver of any subsequent breach or other covenants or conditions.

14. Section Headings:

Section titles or captions are for convenience only and do not define, limit, or describe the scope or intent of this Agreement.

15. Invalid Provisions:

The invalidity or unenforceability of any provision shall not affect any other provision. This Agreement shall be construed as if such invalid or unenforceable provisions were omitted.

16. Counterparts:

This Agreement may be executed in multiple counterparts, each of which shall be deemed an original and all of which shall constitute a single Agreement.

17. Consent:

By signing this agreement, you authorize:

• Internal Medicine of Boynton Beach, Wave Concierge, and its physicians, staff, employees, agents, and representatives to share confidential personal health information with other treating physicians, hospitals, healthcare facilities, and licensed healthcare practitioners for the purpose of fulfilling their obligations under this Agreement.
• Internal Medicine of Boynton Beach, Wave Concierge, and its physicians, staff, employees, agents, and representatives to release any mental health, substance abuse, and HIV/AIDS information contained in your personal health information, but only if your separate, written consent is obtained.
• Internal Medicine of Boynton Beach, Wave Concierge, and its physicians, staff, employees, agents, and representatives to send your personal health information via e-mail to the address listed below.

18. Insurance Information: Provide your health insurance information below. (As printed on your I.D. card) Your Insurance Card Front and Back will be kept on file.

Acknowledgment and Agreement Clause:

By signing below, you acknowledge that you have read, understood, and agree to the terms and conditions detailed in this Membership Agreement. Your signature confirms your thorough review of this document and your comprehension of the commitments and obligations it entails.

Detailed Review and Understanding: You confirm that you have carefully examined every section of this Agreement and understand its implications, including the scope of services provided, membership fees, insurance and co-payment policies, refund policy, and termination procedures.

Consultation and Clarification: You acknowledge that you have had the opportunity to seek clarification on any aspects of this Agreement. Our team has addressed all your questions, providing the information needed for you to make an informed decision about your participation in this program.

Commitment to Compliance: Your signature signifies your acceptance of the terms and conditions specified in this Agreement and your commitment to comply with all provisions, including timely payment of membership fees and adherence to outlined policies.

Authorization and Consent: You consent to the sharing and management of your personal health information as described, including electronic communications and coordination with other healthcare providers as necessary.

Binding Agreement: This Agreement constitutes a binding contract between you and Wave Concierge and Internal Medicine of Boynton Beach. By signing, you understand the legal significance of this document and agree to uphold your responsibilities as a member.

Final Confirmation: By signing below, you attest that you are entering into this Agreement voluntarily, with a clear understanding of its contents, and a commitment to the standards of care and service provided by Wave Concierge and Internal Medicine of Boynton Beach.