Terms and Conditions

Amerihealth Group LLC

MEMBERSHIP AGREEMENT

Patient Contract

 

This Membership Agreement (the “Agreement”), together with Appendix I, II, III, IV, VI, VII, (available on our website) and Member Application constitutes the Patient Contract between You (hereinafter “Member”, “you” or “patient”), and Levi H Lehv, M.D., P.C., and AG Urgent Care PC., (hereinafter “Amerihealth Group LLC” or “AG”).

I        Membership Plan Benefits

  • Included Benefits: AG Members in good standing shall be entitled to Unlimited Urgent Care visits for adults and/or pediatric for $125.00 per member per month for Silver Plus plan, for $250.00 per member per month for Gold Plus plan, for $400.00 per member per month for Platinum Plus plan.

All treatment, testing and care are identified on Appendix I, II, III.

  • THIS AGREEMENT DOES NOT COVER HOSPITAL STAYS, EMERGENCY ROOM VISITS, SERVICES OF SPECIALISTS NOT EMPLOYED BY AG, TREATMENT (INCLUDING BUT NOT LIMITED TO IMAGING) PROVIDED ANYWHERE OTHER THAN AT AG’S FACILITIES, AND ALL LAB TESTS OTHER THAN THOSE IDENTIFIED ON APPENDIX I, II, III.
  • ALL SALES ARE FINAL AND CANNOT BE CANCELLED. Once an order is placed, our vendors are also unable to cancel, make changes, or modify any order. The submission of any order fully acknowledges your agreement to this Membership Agreement.

 Fees for Services & Payment:

The AG Membership fees are $ 25.00, $125.00, $250.00, $400.00, per member per month depending on plan choice. There is a $15.00 co-payment for initial visit and $10 co-payment for all initial visits for Silver Plus and Gold Plus Plans respectively. The other plans do not have a co-payment for any services.

The membership fee for the first three months shall be due and payable upon initial enrollment for members who are paying by cash or by check. Please be advised that you will not receive a monthly bill. For continuation of your membership payment must be received by the 25th of the preceding month. Thereafter, unless otherwise agreed upon (or as may be set forth in the Electronic Funds Transfer Authorization), all credit card charges or other electronic funds transfers shall be processed on the 25th of the month in advance. Please note that there is a grace period of five days after the due date. Membership payments made on the first of the month or after are subjected to a late fee of $2.99.There will be a termination fee in the amount of $200.00 for Silver Plus Plan and $350.00 for Gold Plus Plan $500 for Platinum Plus Plan, in the event of a membership cancellation prior to the one year agreement.

Discounts are available for members who refer other Members to AG. Membership fees are non-refundable.

 

Family Plans:

Family plans are available for families with two or more members. There will be a monthly 10% premium discount for each family member regardless of the plan chosen. The family plan is a one year agreement. There must be two active members on the plan in order to qualify for the 10% discount. Early termination fee will apply in the event of membership cancellation prior to completion of one year.

 

Group Plans:

Group is considered to be eight members or more. Please call to inquire for pricing.

 

  • Term:

The term of this Agreement (the “Term”) is for a period of six months for the Silver Plus Plan or one year for the Gold and Platinum Plus Plans, from effective date. Upon the expiration of the Term this Agreement shall automatically continue upon the same terms and conditions as contained herein, on a month-to-month basis. After the expiration of the Term a Member may cancel this Agreement at any time upon one month’s advance written notice to AG’s Corporate Office, provided however, that the Member pays all Membership fees through the date of cancellation. Notwithstanding, AG reserves the right in its sole and absolute discretion to terminate the membership of any Member for any reason.

 

  • Business Hours & Locations:

Brooklyn:

Bushwick Location

Address:1349 Broadway, Brooklyn NY 111221

Hours: Mon – Fri 9am to 10pm, Sat-Sun 10am to 6pm

 

Flatbush Location

Address: 1576 Flatbush, Brooklyn, NY 11210

Hours: Mon – Fri 9am to 10pm, Sat-Sun 10am to 6pm

 

Mailing Address for Notices:

Address: 4809 Avenue N Suite 273 Brooklyn NY 11234

Hours: Mon-Fri 9am-5pm

 

*Not all services may be available at all locations. Hours of operation may be subject to change without notice.

 

  • Policies:

(A) Appointments/Cancellation. Appointments are required for all visits except those involving urgent care. Members are requested to provide no less than 24 hours’ notice to AG in the event of cancellation of an appointment. Each Member must present his or her photo identification and AG membership card at the time of each visit. AG reserves the right to decline to treat any person who fails to present his or her photo identification and AG membership card at the time of visit.

 

(B) After Hours/Emergency Contact. To reach the MD Hotline for medical advice, please download our app on our website (www.agurgentcare.com), after registration, contact the hotline and listen for the prompt to be connected to a Physician or Physician Assistant or Nurse Practitioner.

 

(C) Membership Cancellation. AG reserves the right to cancel the membership of any Member who fails to promptly pay all membership fees when due and/or maintain a valid credit care on file with AG at all times. There will be a termination fee in the amount of $200.00 for Silver Plus Plan and $350.00 for Gold Plus Plan $500 for Platinum Plus Plan, in the event of a membership cancellation prior to the one year agreement.

 

(D) Privacy. All Members must sign a Patient Notice of Privacy Practice at the time of initial visit.

 

(E) Medical Records. Records, including lab results, are generally not available on a walk-in basis. A medical records release form must be filled out, including patient signature and date. It may take up to ten business days for a Member’s request to be processed and for records to be made available.

 

  • Dispute Resolution:

Any dispute, claim or controversy arising out of or relating to the performance of medical services, including but not limited to, member fees, informed consent, negligence or medical malpractice, between Member (whether a minor or an adult) or the heirs-at-law or personal representative of the Member, as the case may be, and AG and each AG physician or staff member, individually, where the claim or amount in controversy exceeds $5,000.00, such dispute or controversy shall be submitted to arbitration in the County of New York, State of New York pursuant to the rules then obtaining of the American Arbitration Association. The determination of the arbitration shall be final and binding, and may be enforced in the Federal or State courts located within the State of New York, County of New York, to which jurisdiction the parties hereto agree to submit.

VII. Miscellaneous:

 

  • This Agreement may not be assigned by the Member.

 

  • AG reserves the right to alter and amend the terms of the Patient Contract from time to time by AG, without advance notice to you.

 

  • If a parent or guardian has signed on behalf of their minor child or ward, such parent or guardian hereby attests that he or she has full legal authority to execute this arbitration agreement on behalf of said child or ward. Further, said parent or guardian hereby agrees to indemnify and hold harmless, including legal fees. AG from any claim, demand or loss which may occur in the event said parent or guardian does not, in fact, have such legal authority.

 

  • Except as otherwise provided herein, this Agreement shall be binding upon and inure to the benefit of the parties and their legal representatives, successors and permitted assigns. The headings in this Agreement do not form a part of the Agreement and shall not be taken into account in interpreting this Agreement.

 

  • No-Cancellation Policy All sales are final and cannot be cancelled. We cannot accommodate changes or refunds.

 

  • Additional charges may apply for certain order specifications. Availability and charges for these specifications will vary between vendors and will display with each service or product.

 

  • In the event that any provision herein contained is held to be invalid, void or illegal by any court of competent jurisdiction, the same shall be deemed severable from the remainder of this Sublease and shall in no way affect, impair, or invalidate any other provision herein contained. If such provision shall be deemed invalid due to its scope or breadth, such provision shall be deemed valid to the extent of the scope or breadth permitted by law.

 

THIS AGREEMENT IS NOT, AND IS NOT INTENDED TO BE, AN INSURANCE CONTRACT. AG REPRESENTS, AND THE MEMBER ACKNOWLEDGES THAT THE MEMBERSHIP FEE CONFERS ONLY THOSE BENEFITS IDENTIFIED HEREIN. FEES CHARGED BY AG FOR ADDITIONAL SERVICES ARE REASONABLE AND INTENDED TO COVER THE COST OF PROVIDING SUCH SERVICE INCLUDING REASONABLE OVERHEAD.

NOTICE: BY SIGNING THIS AGREEMENT YOU ARE AGREEING TO HAVE ANY CLAIM OF NEGLIGENCE OR MEDICAL PRACTICE, OR ANY OTHER CLAIM, DECIDED BY A NEUTRAL BINDING ARBITRATION AND YOU ARE GIVING UP YOUR STATUTORY AND CONSTITUTIONAL RIGHT TO PROCEED WITH YOUR CLAIM IN COURT BY MY SIGNATURE BELOW I ACKNOWLEDGE THAT I HAVE RECEIVED AND REVIEWED THE PATIENT CONTRACT. ALL PROVISIONS HEREOF, AS WELL AS ALL QUESTIONS PERTAINING HERETO, HAVE BEEN FULLY AND SATISFACTORILY EXPLAINED TO ME. I HAVE GIVEN DUE CONSIDERATION TO SUCH PROVISIONS AND QUESTIONS, AND I CLEARLY UNDERSTAND AND CONSENT TO ALL THE PROVISIONS HEREOF.

 

  • BY ACCEPTING THIS MEMBERSHIP AGREEMENT, YOU ACKNOWLEDGE THAT YOU UNDERSTAND AND AGREE WITH THE TERMS STATED IN THIS CONTRACT.