THIS MEMBERSHIP AND THE PREPAID SERVICES PROVIDED UNDER THIS CONTRACT ARE NOT INSURANCE

 

CAGE FREE CARE PREPAID PRIMARY CARE MEMBERSHIP CONTRACT

 

  1. The Cage Free Care Membership Program is not health insurance and does not substitute for insurance in any way. It does not meet the Patient Protection and Affordable Care Act requirements for insurance and does not constitute “creditable” insurance coverage. It is a prepaid Membership program provided in accordance with Texas law.

Membership Program. In this Membership program, you are selecting a limited amount of in person direct primary care provided by your physician, who is identified on Attachment A (“Provider”). Although you and your Provider are using the Cage Free Care platform to contract, this Contract is between you and your Provider.  As used in this contract, the term “direct primary care” means those services that the Member has purchased and Provider is qualified to provide under his professional license at the Provider’s office (for scheduled in person visits under the Doctor Plan or Cage Free Care Plus Plan) or at a participating free standing emergency room facility (for the Emergency Plan or Cage Free Care Plus option)  located at any one of the addresses shown on Attachment A.   Direct primary care also means the telemedicine visits offered by the Telemedicine Providers listed in this Contract, the cost of which is included in your care plan while your Membership is active and you are a patient of the Provider.

 

Prepaid Base Plan Membership Benefits. By purchase of this prepaid Membership, you are purchasing the amount of direct primary care from your Provider described for the package you selected.  This direct primary care is offered by your Provider at the specified office or free standing emergency room facilities applicable to the care plan you have selected, shown on Attachment A, and pursuant to the following National Provider Identifiers or billing numbers: ___________. Although your Provider advertises services on the third-party website at the address www.CageFreeCare.com on which other direct primary care providers may also advertise, the Provider is not associated with those other providers and does not own or control the third-party website. You, as a member, are not precluded from signing up for other services advertised on the Cage Free Care third-party website, but the Provider is not responsible for providing any of the services advertised by other providers on the third-party website.

 

  1. Number of prepaid visits. Membership will cover the full cost of the care rendered by your Provider under the selected prepaid option (listed below) for the allowed number of facility-based visits within a 12-month period (the “Membership Year”) as described below:

For the Provider you have selected, you may make one of the selections for direct primary care—

      (1) The Doctor Plan (includes an unlimited number of in person direct primary care visits with your Provider on a scheduled basis in an office setting plus unlimited Telemedicine through a Telemedicine provider as long as your Membership is active);

      (2) The Emergency Plan (includes a limited number in person direct primary care visits with your Provider at any of the free standing emergency room facilities listed in this Contract on an emergency basis, plus unlimited Telemedicine through a Telemedicine provider as long as your Membership is active); or

      (3) The Cage Free Care Plus (includes unlimited in person direct primary care from your Provider on a scheduled basis in an office setting plus limited direct primary care from your Provider at any of the free standing emergency room facilities listed in this Contract on an emergency basis, plus unlimited Telemedicine through a Telemedicine provider as long as your Membership is active).

 

Doctor Plan:  The Doctor Plan visits are in person and are not limited in number during the Membership Year (however, they must be scheduled and must occur during posted office hours in the Provider’s office as listed in this Contract and designated during scheduling).  This selection allows your Provider to provide you with management of chronic illnesses and high blood pressure, well woman exams, STI testing, annual wellness physicals, sports physicals, travel medicine, pediatric care over age 2, simple suture repair, incision and drainage of wounds, sick visits and uncomplicated psychiatric drug management.  For each membership category (individual, couple, or family), direct primary care visits under the Doctor Plan  are unlimited during the Membership Year and are conducted by appointment with your Provider.  You can make your appointment using the Cage Free Care portal.

 

No Free Standing Emergency Room facility visits are included in the Doctor Plan.

 

While your Doctor Plan is in effect, you are also entitled to unlimited direct primary care using telemedicine, which will be provided by the Telemedicine Provider listed in your Contract.

 

Emergency Plan:  The Emergency Plan visits are in person, are limited in number (the number allowed is based on your selection of Individual, Couple, or Family services), and consist of a limited number of direct primary care facility based visits with your Provider at the free standing emergency room facilities listed in this Contract on an emergency (unscheduled) basis.  While your Emergency Plan is in effect, you are also entitled to unlimited direct primary care using telemedicine, which will be provided by the Telemedicine Provider listed in your Contract.

 

If you select the Emergency Plan, Individual Emergency Room visits, Couple Emergency Room visits, or Family Emergency Room visits are provided in the amount(s) listed below.

  1. Individual Emergency Room visits – 4 free standing emergency room facility-based visits per year;
  2. Couple Emergency Room visits – 6 free standing emergency room facility-based visits per year (any Member of the couple using a visit will be counted against the total);
  3. Family Emergency Room visits – 8 free standing emergency room visits per year (any family Member using a visit will be counted against the total).
  4. Rollover features. An individual, couple, or family, as applicable, can, for every two facility-based visits not used in a Membership Year, roll over one or more of the unused facility-based visits to the next Membership Year (if the Membership Year is timely renewed). The maximum rollover Membership visits permitted is one half of the current Membership Year’s total facility-based visits.
    1. For example, if an individual had two unused facility-based visits at the end of the Membership Year, he could roll over one to the next Membership Year when he renewed and would then have five total Membership Year facility-based visits for the renewed Membership Year.
    2. There are no half-visit rollover credits, so the unused facility-based visits at the end of the Membership Year must be evenly divisible by two to roll over. Rolled over visits have no cash value and are not refundable or otherwise
  5. Membership Additional Packages-subject to the exclusions set out in this Contract, Membership will cover the full cost of the care rendered by the Provider set out on Attachment A as associated with the package purchased.
  6. Labs, treatments, procedures, x-rays, EKG, CT. All tests and procedures performed by Provider at Provider’s facility if you have selected the Emergency Plan will be considered part of the pre-paid facility-based visits under the Emergency Plan.

 

NOTE:  None of the Membership Plans described above include prescription drugs prescribed or medical devices or equipment ordered by the Provider and obtained by the Member from a pharmacy or other source that is not at a Provider free standing emergency room facility listed in this Contract and provided in connection with the Emergency Plan or Cage Free Care Plus..

 

Cage Free Care Plus:  The Cage Free Care Plus direct primary care selection provides you with the services available under the Doctor Plan plus the Emergency Plan, and includes unlimited direct primary care through the Telemedicine Provider listed in your Contract during the time your Cage Free Care Plus care plan is in effect.

 

  1. Membership fees. Your Cage Free Care Membership simply allows you and your Provider to contract for direct primary care and to communicate using the Cage Free software and the website platform maintained by Cage Free Care. Cage Free Care is not a health care professional.  Your contract with your Provider becomes effective at 12:01 a.m. on the 15th consecutive calendar day after you initially sign up and pay your membership and Registration/Processing Fee (“Effective Date/Time”) (initial payment may be made using the online portal or in the Provider facility; note that returned checks or other forms of denied payment do not constitute payment of the membership and registration fees). During the period prior to the Effective Date/Time, you do not have Membership benefits at Provider. Note that any renewal of this Contract is renewed at the prices in effect at the time of the renewal, which can be higher than the prices shown in this Contract.  The prepaid cost of Membership is as follows:

 

Fees for “Dr. Plan” Contract with your Provider:

 

  1. Fee for Individual Membership is fully earned (subject to cancellation/refund rules contained in this contract) but is payable in increments of $60 per month, plus a one-time registration/processing fee (“Registration/Processing Fee”) of $25;
  2. Fee for Couple’s Membership is fully earned (subject to cancellation/refund rules contained in this contract) but is payable in increments of $80 per month, plus a one-time Registration/Processing Fee of $35;
  3. Fee for Family Membership (up to 6 people related by blood or legal adoption) is fully earned (subject to cancellation/refund rules contained in this contract) but is payable in increments of $125 per month plus a one-time Registration/Processing Fee of $35.
    • Add $25 per month for additional family members.
  4. If you have any gap between Membership Years, a new Registration/Processing Fee at the then-current price will be due in addition to the membership
  5. Additional and Penalty Fees:
    • Must cancel appointment 24-hours prior to scheduled appointment to avoid penalty of $25;
    • First ID card = $5.00 (Hard copy);
    • Lost ID card = $8.00 (Hard copy) but free email;
    • Address change = $8.00 (Hard copy) but free email;
    • Merging family = $8.00 (Hard copy) but free email;
    • Buying additional services after initial start date will generate new email ID card for free, but Hard Copy will be $8.00.

Fees for “Emergency Plan” Contract with your Provider:

 

  1. Fee for Individual Membership is fully earned (subject to cancellation/refund rules contained in this contract) but is payable in increments of $139 per month, plus a one-time registration/processing fee (“Registration/Processing Fee”) of $25
  2. Fee for Couple’s Membership is fully earned (subject to cancellation/refund rules contained in this contract) but is payable in increments of $228 per month, plus a one-time Registration/Processing Fee of $35;
  3. Fee for Family Membership (up to 6 people related by blood or legal adoption) is fully earned (subject to cancellation/refund rules contained in this contract) but is payable in increments of $289 per month plus a one-time Registration/Processing Fee of $35.
    • Add $25 per month for additional family members.
  4. If you have any gap between Membership years, a new Registration/Processing Fee at the then-current price will be due in addition to the membership fee.
  5. Additional and Penalty Fees:
    • Must cancel appointment 24-hours prior to scheduled appointment to avoid penalty $25;
    • First ID card = $5.00 (Hard copy);
    • Lost ID card = $8.00 (Hard copy) but free email;
    • Address change = $8.00 (Hard copy) but free email;
    • Merging family = $8.00 (Hard copy) but free email;
    • Buying additional services after initial start date will generate new email ID card for free, but Hard Copy will be $8.00.

 

Fees for “Cage Free Care Plus” Contract with your Provider:

 

  1. Fee for Individual Membership is fully earned (subject to cancellation/refund rules contained in this contract) but is payable in increments of $150 per month, plus a one-time registration/processing fee (“Registration/Processing Fee”) of $25;
  2. Fee for Couple’s Membership is fully earned (subject to cancellation/refund rules contained in this contract) but is payable in increments of $250 per month, plus a one-time Registration/Processing Fee of $35;
  3. Fee for Family Membership (up to 6 people related by blood or legal adoption) is fully earned (subject to cancellation/refund rules contained in this contract) but is payable in increments of $335 per month plus a one-time Registration/Processing Fee of $35.
    • Add $25 per month for additional family members.
  4. If you have any gap between Membership years, a new Registration/Processing Fee at the then-current price will be due in addition to the membership fee.
  5. Additional and Penalty Fees:
    • Must cancel appointment 24-hours prior to scheduled appointment to avoid penalty $25;
    • First ID card = $5.00 (Hard copy);
    • Lost ID card = $8.00 (Hard copy) but free email;
    • Address change = $8.00 (Hard copy) but free email;
    • Merging family = $8.00 (Hard copy) but free email;
    • Buying additional services after initial start date will generate new email ID card for free, but Hard Copy will be $8.00.
  1. Payment portal. All monthly payments for this prepaid Membership program will be paid to the Provider by the Member exclusively through the online portal at www.cagefreecare.com. Monthly invoicing and payment with cash or check is NOT available. Monthly Membership payments are paid using the online portal via recurring credit card billing, or recurring bank draft (checking or savings account) only.
  1. Additional charges. Your Membership will not pay for the following:
  1. EMS Transfer or other transfer to another facility and treatment at that facility;

b.       Hospitalization;

  1. Follow up with specialists or treatment by other medical professionals who are not available at the Provider’s free standing emergency room facility and are not part of the Provider’s medical group;
  2. Prescription drugs prescribed, or medical devices or equipment ordered by the Provider and obtained by the Member from a pharmacy or other source that is not at a Provider’s free standing emergency room facility; and
  3. Any other procedures not provided by Provider at a free standing emergency room facility listed in this contract.
  1. Membership Year is 12 consecutive months, beginning on the Effective Date/Time (as defined in this Contract). For example, a Membership Year that begins February 15 of this year will end at midnight on February 14 of next year (subject to the automatic renewal provisions, described in paragraph 8).
  1. Automatic renewal. At the end of the 12-month contract period the contract will be automatically renewed unless the Membership is cancelled by the Member in writing 30 days prior to the end of the initial contract period. Your Provider, who is using the Cage Free Care platform reserves the right to increase or decrease the prepaid rate of your Membership program after the initial 12 month Membership Year and for any subsequent Membership Year at renewal—your Provider’s current prices will be listed on the Cage Free Care portal. At the end of the 12-month Membership Year a renewing Member should timely make recurring payments based upon the then-current cost of the Cage Free Care Membership program as set by your Provider—any automatic draft payments that you set up at the time you originally contracted with your Provider using the Cage Free Care platform will continue until you cancel those payments. If a Membership is renewed and not paid in full by the renewed Member, it will be cancelled as set out in this contract. Partial payments are not

 

  1. Cancellation & Collection Policy. To communicate your cancellation of your contract with your Provider in order to prevent an on-going month-to-month automatic draft please contact the Cage Free Care Customer Support Department in writing at least 30 calendar days prior to the end of the then current Membership Year. Cancellation must be in writing with a 30-day advance notice and submitted to support@Cagefreecare.com or call the Cage Free Care Customer Care representative at (512) 851-1018. The requirements for other cancellation periods are specified below:
  1. Cancellation within 30 days following the Effective Date/Time, if no prepaid in person visits with your Provider have been incurred, will result in a full refund minus the $25 processing registration fee. Telemedicine visits, if any have been incurred prior to cancellation, will be deducted from the refund amount at $25 per
  2. Cancellation within 30 days following the Effective Date/Time, if visits are incurred, will result in invoicing for each visit at usual and customary rates or rates that would apply to your care by the Provider without the Cage Free Membership platform.
  3. Cancellation after 30 days, and before the 12-month Membership Year ends, will result in a 50 percent balance of the remaining unpaid 12-month contract price remaining
  4. Cancellation will occur automatically for nonpayment after 60 days and former Members will be referred to a collection agency for the outstanding balance of the 12-month contract. A 35 percent collection fee, including, but not limited to attorney fees and interest will be added to your contract
  5. Cancellation within 30 days after the start of a renewal period will result in an obligation to pay 50 percent of the Membership fee for that renewal period either as a lump sum or billed and paid in accordance with the payment provisions in place at the time of the
  6. No visits of any type occurring after cancellation will be considered pre-paid.

9.              Applicable     Proof     of     Identity     and     Communication/Authorization/Consent Requirements.

 

  1. A valid, government-issued picture ID for each adult Member is required to obtain services from a Provider using the Cage Free Care Program platform.
  2. A valid picture ID for each adult Member and a Provider-issued photo on file for each minor Member is required at the time of service for verification of identity before receiving free
  3. Members are required to have their picture taken and stored in the Cage Free Care database for your Provider’s use for future
  4. Members must agree to allow Cage Free Care team to communicate with them via email, text, and telephone on behalf of your Provider.
  5. Anyone under the age of 18 may enroll as a Member only if a parent or legal guardian is financially responsible for the
  6. Minors must have their parent or legal guardian available to give consent to be evaluated and treated by
  7. Any Member who may also have any private or governmental health insurance benefits or plan for which Provider is contracted to be a provider, agrees NOT to seek reimbursement of payment from Member’s private or governmental health insurance benefits or plan for services received from your Provider under this Cage Free Program. This restriction does not apply to free standing emergency room facility-based care that a Member receives from any Cage Free Program facility or Provider if the Member has already exhausted all Cage Free Program pre-paid free standing emergency room facility-based visits for the Membership Year

Conditions under which Provider services are offered.

  1. Medical services provided by Provider in accordance with this Contract are provided within the scope of direct primary medical care services as defined by Texas
  2. Provider reserves the right to refer ANY Members to other facilities, medical providers or specialists who are not part of your Cage Free Care selected Membership plan for further evaluation and treatment as Provider deems medically necessary when rendering care. Payment to such referred facilities, other medical providers or specialists is Member’s sole
  3. Provider is not responsible for any type of emergency transport to other facilities, medical providers or specialists who are not part of Cage Free
  4. All Members agree to follow Provider’s medical advice for primary
  5. Members may not dictate how the Provider should diagnose or treat
  6. Although your Care Free Care Providers rely on Members to provide complete and honest answers to questions regarding prior medical history to aid diagnosis and treatment, Members may not tell the Provider what labs, tests x-rays or referrals to order, or not to
  7. All care and services provided by Provider under the Cage Free Membership will be determined based upon their medical necessity as determined by the Provider directly rendering care to the
  8. The Member hereby represents to the Provider and to all persons and entities that provide professional and technical services to the Provider or that submit billings on behalf of such persons or entities that the Member (and none of the other spouse or family Members for whom Member is making this representation, as listed on this contract) are or will become Medicare beneficiaries during the term(s) of this
  9. The Member hereby represents that for any minor Member signed up for direct primary medical care, Member has the primary responsibility to provide payment for that direct primary medical care to benefit said minor

j.        The Member understands and agrees that the Provider does NOT render the following care:

  • Chronic pain management;
  • Long term treatment with controlled medications and substance;
  • Substance abuse or withdrawal;
  • Advanced psychiatric problems;
  • DOT physicals;
  • Worker’s compensation care; and
  • Vaccinations

 

  1. The Provider reserves the right to refuse Membership to any person for any reason allowed by applicable
  2. Cage Free Care reserves the right to refuse use of its software and website to any person for any reason allowed by applicable law.
  1. Any legal action against Cage Free Care, Providers, its and their related entities, agents, employees, representatives, affiliates and/or facilities, for any omission or action regarding an obligation to the Member, must be commenced within one (1) year from the date the omission or action was, or should have been,

 

  1. All information required to be provided to Cage Free Care under this contract should be provided by the Member in writing to the following address:

 

Attention:  _______________________________ [Provider]

Cage Free Care, 3620 E Whitestone Blvd, Cedar Park, TX 78613.

 

Provider can be contacted by telephone or email at Customer Care representative

– (512) 851-1018, support@cagefreecare.com.

 

  1. Applicable Law. This contract shall be governed by and construed under the laws of the State of Texas and any applicable federal laws. Provider will not provide any services pursuant to this contract that applicable law does not permit Provider to
  1. No Assignment. This contract is not assignable by any Member. Provider may assign this contract to a professional association or other qualified provider or entity as permitted by applicable
  1. Severable Provisions. If any provision of this contract, or portion thereof, is determined by a court or other applicable adjudicatory body of competent jurisdiction, or declared under any law, rule or regulations to be illegal or unenforceable, then such provision will, to the extent permitted by the court or other applicable adjudicatory body, not to be voided but will instead be construed to give effect to its intent to the maximum extent permissible under applicable law and the remainder of this contract will remain in full force and effect according to its
  1. Entire Contract. This contract constitutes the entire contract of the parties concerning its subject matter and supersedes any and all prior or contemporaneous, written or oral negotiations, correspondence, understandings and contracts between the parties concerning its subject matter of this contract. No supplement, modification, or amendment to this contract shall be binding unless evidenced by a writing signed by the party against whom it is sought to be enforced. No waiver of any of the provisions of this contract shall be deemed or shall be binding unless executed in writing by the party making the

The Member(s) subject to this Contract are listed below, with full names, birthdates, address (street and mailing address), telephone and email address (if applicable).

 

I have read and understand this entire contract. I agree to participate in the Cage Free Membership Program under the terms and conditions set out in the contract.   If I am purchasing a couple or family Membership, I represent to Provider that my signature below is provided with authority to bind my spouse (for a couple’s Membership) and all of my listed family Members (for a family Membership). I further represent to Provider that the Membership in the Cage Free Membership program is, for each Member listed below, that Member’s main source for direct primary medical care services as required by Texas Occupations Code Chapter 162, Subchapter F. 

 

 

Plan Selected:  ______________________________________________

 

Name:                                                                   Date:

 

    
    

Print Name Here

 

 

Credit Card Holders Signature:                        Date:

 

    
    

Print Name Here

 

 
  

Print Name Here (if different from Member)

 

Member name(s):

 
  

 

 
  

Member birthdate(s) (by Member):

 

 
  

 

 
  

Member street address (by Member):

 

 
  

Member mailing address(es) (by Member):

 

 
  

 

ATTACHMENT A

 

Provider:__________________________________________________

 

Provider’s facility location addresses (telemedicine access information):

 

  1. Family Emergency Room at Cedar Park

3620 E Whitestone Blvd

Cedar Park, TX 78613

  1. Family Emergency Room at Round Rock

1925 South AW Grimes Blvd

Round Rock, TX 78664

  1. Family Emergency Room at Lake Travis

5012 N FM RR 620

Austin, TX 78732

  1. Family Emergency Room at Georgetown

1210 W University Ave

Georgetown, TX 78628

  1. Family Emergency Room at Lakeline

1860 S. Lakeline Blvd.

Cedar Park, TX 78613

 

Provider’s office addresses (contact Provider for an appointment using the Cage Free Care Portal):

 

Family Emergency Room at Lakeline

1860 S. Lakeline Blvd.

Cedar Park, TX 78613

(512) 506-8503

 

Telemedicine Services provided during the term of this Contract are provided by Dr. Pratt and Dr. Schaefer of Teleconsult.

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