Brave Care Patient Agreement
Effective Date: June 9, 2019
Updated: March 2, 2022
This Patient Agreement (this “Agreement”) governs your use of the medical services (“Medical Services”) provided by Pacific Crest Children’s Urgent Care, LLC, Brave Care Pediatrics NC, P.A., and other medical practices (collectively, “Brave Care” “we” or “us”) affiliated with Brave Care Technologies, Inc. (“Brave Care Technologies”). Please read this Agreement carefully before receiving medical services from Brave Care.
By signing this Agreement as either the patient, or patient’s legal representative, guardian, conservator, or custodian of a minor child (under 18 years of age) or other person lacking the ability to consent (collectively “You”), You acknowledge to have read, accepted and become legally bound to the terms and conditions set forth below, including in the Telehealth Services Consent contained herein and the Code of Conduct for Patients as attached. The terms “You” or “you” shall also mean the patient or recipient of health care services. We reference the Brave care website as the “Site” and the Brave Care app as the “App” in this Agreement.
Please refer to our Notice of Privacy Practices to learn how Brave Care may collect, use, share and protect your Protected Health Information (as defined under the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, i.e., “HIPAA”).
DO NOT USE THE MEDICAL SERVICES, INCLUDING THE TELEHEALTH SERVICES, FOR EMERGENCY OR LIFE-THREATENING MEDICAL MATTERS. FOR ALL LIFE THREATENING MATTERS, IMMEDIATELY CALL 911 OR GO TO THE NEAREST EMERGENCY ROOM.
1. Updates to the Agreement
Brave Care may, in its sole discretion, without prior notice to You, revise this Agreement at any time. Should this Agreement change materially, Brave Care will update the “Updated” date noted above and post a notice regarding the updated Agreement. If You do not agree with the proposed changes, You should discontinue your use of the Medical Services before the effective date of the change. If You continue using the Medical Services after the Updated date, you will be bound by the updated Agreement.
2. Your Financial Responsibility; Assignment of Benefits
You agree to pay Brave Care all applicable charges and payment responsibility at the prices then in effect for the Medical Services provided to You or another person on whose behalf You are accepting this Agreement (such as your children or other family members) (each a “Covered Family Member”), and in accordance with the financial policy set forth in Section 2.1 of this Agreement. You will be charged for the Medical Services provided to You or Your Covered Family Member by a Brave Care practitioner. You authorize Brave Care and its agents to charge Your chosen payment method (Your “Payment Method”) for the Medical Services provided to You or Your Covered Family Member. If Your Payment Method is invalid at the time payment is due, You agree to pay all amounts due upon demand. The third-party services provider who manages Your Payment Method may impose terms and conditions on You, which are independent of this Agreement, and You agree to comply with all of those terms. Brave Care may accumulate charges that you have incurred for the Medical Services and submit them as one or more aggregate charges during or at the end of each billing cycle. Brave Care reserves the right to correct any billing errors or mistakes even if payment has already been requested or received.
If You provide information about Your health insurance or health plan, that will be deemed Your authorization for us to submit claims for covered Medical Services to your health insurer or health plan. You hereby assign or otherwise authorize payment of medical benefits to Brave Care for the Medical Services provided to You or Your Covered Family Member. You authorize the release of any medical or other information necessary to process any claims for the Medical Services provided. You further understand and accept Your financial responsibility for any portion of the bill not covered by your health insurer or health plan. SUBMISSION OF CHARGES DOES NOT WAIVE OUR RIGHT TO SEEK PAYMENT DIRECTLY FROM YOU.
2.1. Financial Policy
You agree that all payments are due at the time of service. Co-pays not paid at the time of Your visit may be subject to an additional charge to Your account. Patients who are not using insurance and are instead paying on a “cash” basis must pay in full at the time of service. If Your check is returned for non-sufficient funds (NSF), we will add a service charge to Your account. If that happens, you will be asked to pay the amount of the check plus the service charge within ten (10) days of the date of service. If the outstanding liability on Your account has not been paid in full by then, it may be referred for collection action. If Your insurance plan does not cover a procedure, You agree to sign a waiver agreeing to pay for the visit at the time of service.
You agree to present Your insurance card at each visit to ensure that we bill Your insurance correctly. If we determine that the charges for the visit will be applied to Your deductible, You will be given the opportunity to pay a portion of the charge for the next visit. This payment will be submitted to Your insurance company. Depending on the services provided, there may be a credit or an additional charge to Your account.
If You have coverage through a non-contracted insurance plan, we will provide You with a coded bill to submit to Your insurance company. It is Your responsibility to follow up with your insurance company and pay the bill in a timely manner.
Payments may be made at our office, online, or by phone. If you are having financial difficulty, we may be able to establish a payment plan. If a payment plan is established, You agree to abide by any and all terms of the payment plan. If You fail to pay or contact our business office within sixty (60) days after a statement is issued, our collections process on your account will begin. Repeated failure to pay may result in Your dismissal from Brave Care and the assignment of Your account to a collection agency. In the event of non-payment, a rebilling fee/finance charge will be applied to any overdue balance.
3. Permission to Treat
You hereby give permission to Brave Care to medically care for your Covered Family Member or You. You may withdraw this consent at any time by no longer seeking Medical Services from Brave Care. You understand that if You refuse recommended medical care, You will not hold Brave Care, any of its staff or physicians, or any other practitioner (each a “Brave Care Clinician”) responsible for any consequences of Your refusal of care.
You understand and agree that as part of providing Medical Services to your Covered Family Member or You, your PHI, including test results, may be released to an online personal health record and via communication with Brave Care Clinicians electronically (in accordance with our Notice of HIPAA Privacy Practices ).
4. No Show Policy
You agree provide notice at least twenty-four (24) hours prior to Your appointment if You will be unable to attend. If You miss a second appointment without twenty-four (24) hours’ advance notice, a fee of $25.00 (twenty-five) dollars to $50 (fifty) dollars may be charged. A third missed appointment without advanced notice in a twenty four (24) month period can be cause for dismissal from Brave Care for the patient and the patient’s family. Failure to keep an initial appointment to establish care is also cause for dismissal from Brave Care.
5. Service Termination
You may terminate your use of the Medical Services at any time by not using the Medical Services anymore. We may terminate Your use of the Medical Services at any time in our reasonable discretion, for causes including but not limited illegal conduct such as falsifying information to obtain controlled substances, abusive and threatening behavior, and continued refusal to pay for our services. You agree to comply with the terms of the Code of Conduct for Patients, as attached. We may remove You from any Brave Care facility and terminate Your use of the Medical Services for any violation of the Code of Conduct for Patients. We may terminate Your use of the Medical Services by sending notice to You at the mail or email address you provided to us or by otherwise contacting You. If we terminate Your use of the Medical Services, we will use reasonable effort to notify Your insurer, if any.
6. Consent to Electronic Communications
You agree that Brave Care may send the following to you by email or by posting them on our Site and/or App: legal disclosures; this Agreement, including the Telehealth Services Consent, Code of Conduct for Patients, and Notice of Privacy Practices; future changes to any of the above; and other notices, policies, communications or disclosures and information related to the Medical Services.
By signing this Agreement, You agree that Brave Care may contact you via (secure) messaging, email, phone, text, or mail regarding the Medical Services, including electronic communications from Brave Care pertaining to your care and your health, which may include PHI. You understand that communication via email, text messages, and other electronic means selected by Brave Care may not be secure and could be viewed by unintended persons, and you or on behalf of your Covered Family Member agree to exchange of communications, to and from Brave Care via these electronic means. You agree to update your contact information to ensure accuracy.
If you later decide that you do not want to receive certain future communications electronically, please send an email to firstname.lastname@example.org or a letter to Brave Care, 6924 NE Sandy Blvd, Portland, OR 97213. You may also opt out of certain electronic communications through your account or by following the unsubscribe instructions in any communication you receive from Brave Care. Your withdrawal of consent will be effective within a reasonable time after we receive your withdrawal notice described above.
Brave Care will need to send you certain communications electronically regarding the Medical Services. You will not be able to opt out of those communications – e.g., communications regarding updates to this Agreement or information about billing. Your withdrawal of consent will not affect the legal validity or enforceability of the Agreement provided to and accepted by, You.
TO THE MAXIMUM EXTENT NOT PROHIBITED BY LAW, EXCEPT IN CASE OF NEGLIGENCE OR WILLFUL MISCONDUCT, WE AND OUR AFFILIATES, BRAVE CARE, PARTNER PROVIDERS, EMPLOYEES, OFFICERS, DIRECTORS OR AGENTS WILL NOT BE RESPONSIBLE FOR ANY LOSS OR DAMAGE, INCLUDING PERSONAL INJURY OR DEATH, RESULTING FROM ANYONE’S USE OF OR INABILITY TO USE THE MEDICAL SERVICES.
The Medical Services are intended for use only within the United States and its territories. We make no representation that the Medical Services are appropriate, or are available for use outside the U.S. or outside of the states in which Brave Care operates medical practices. Those who choose to access and use our Medical Services from outside the U.S. do so on their own initiative, at their own risk, and are responsible for compliance with applicable laws.
8. Limitation of Liability
TO THE MAXIMUM EXTENT NOT PROHIBITED BY LAW, IN NO EVENT WILL WE AND OUR AFFILIATES, BRAVE CARE PEDIATRICS, PARTNER PROVIDERS, EMPLOYEES, OFFICERS, DIRECTORS OR AGENTS BE LIABLE FOR ANY CONSEQUENTIAL, EXEMPLARY, INCIDENTAL, SPECIAL OR PUNITIVE DAMAGES, INCLUDING WITHOUT LIMITATION THOSE RELATING TO LOST PROFITS OR THE COST OF SUBSTITUTE PRODUCTS OR SERVICES ARISING OUT OF OR IN CONNECTION WITH THE MEDICAL SERVICES OR FROM THE USE OF OR INABILITY TO USE THE MEDICAL SERVICES, WHETHER BASED ON CONTRACT, WARRANTY, PRODUCT LIABILITY, TORT OR OTHER LEGAL THEORY AND EVEN IF WE HAVE BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGES. SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE EXCLUSION MAY NOT APPLY TO YOU.
9. Telehealth Services Consent
Brave Care may directly provide Medical Services to you or your Covered Family Member using virtual technology when the Brave Care Clinician and patient are not in the same physical location, and/or deliver health care services virtually, including by a medical provider or via digital or automated tools, including without limitation tools for medical or health-related diagnosis or treatment (the “Telehealth Services”). Telehealth may be used for diagnosis, treatment, care, follow-up and/or patient education, and may include, without limitation, the following: electronic transmission of patient medical records, medical images, and/or other patient data or information; synchronous (i.e., “real time”) and asynchronous (i.e., non-”real time”) interactions via audio, video, text, and/or data or other electronic communications; automated, electronic or digital tools or services for diagnosis, care, treatment and/or communication pertaining to healthcare or medical matters; and output, transmission or exchange of data from medical devices, sound and video files. You understand that virtual encounters required to receive Telehealth Services via phone, email, video, or otherwise, could involve certain limitations and risk, such as unauthorized disclosure of PHI, and you hereby consent to the use of, automated tools for diagnosis, care, treatment or communication pertaining to healthcare matters. You also acknowledge that such virtual encounters may involve care by a variety of types of Brave Care Clinicians, including physicians, registered nurses, nurse practitioners, physician assistants, , and other support or medical personnel in accordance with applicable laws and regulations.
Unless You object, You give permission to Brave Care to record and process Your personal details and medical data generated during the provision of Telehealth Services. You may withdraw these permissions at any time by no longer seeking Telehealth Services from Brave Care.
10. Use of the Telehealth Services
You agree to the following terms with respect to use of the Telehealth Services:
You understand that there may be possible risks and limitations of the Telehealth Services, including that it may be possible that your condition cannot be treated via the Telehealth Services, or that information transmitted through the Site may not be sufficient or of too poor of image quality, or there may be insufficient information or data to allow for appropriate medical decision making. Accordingly, you may be required to seek additional in-person medical care, alternative healthcare or emergency services. If Your health or medical problem or condition persists after use of the Telehealth Services, you will immediately contact your medical services provider and seek appropriate additional in-person medical care or emergency care, as appropriate.
You understand that in rare circumstances, security protocols could fail, causing a breach of privacy that allows unauthorized persons access to your PHI.
You agree NOT to use the Site using an unsecured public Wi-Fi or other unsecure electronic communication.
You agree NOT to record any audio or visual communication transmitted via the Site, including Telehealth Services, without the express consent of all communicating parties.
You understand that you are responsible for providing accurate information through the Site, including demographics and location information, medical histories, medication use, current adverse conditions, financial information, and keeping all such information current.
You agree to follow all recommendations, protocols and other instructions you receive concerning the use of the Site and from Brave Care concerning the Telehealth Services.
11. Dispute Resolution
Agreement to Arbitrate
You agree that any dispute, claim or controversy arising out of or relating to this Agreement or the Services (collectively, “Disputes”) will be settled by binding arbitration, except that each party retains the right: (i) to bring an individual action in small claims court and (ii) to seek injunctive or other equitable relief in a court of competent jurisdiction to prevent the actual or threatened infringement, misappropriation or violation of a party’s copyrights, trademarks, trade secrets, patents or other intellectual property rights (the action described in the foregoing clause (ii), an “IP Protection Action”). You will also have the right to litigate any other Dispute if you provide us with written notice to opt out of arbitration (“Arbitration Opt-out Notice”) by email at email@example.com or by regular mail to Brave Care, 6924 NE Sandy Blvd, Portland, OR 97213 within thirty (30) days following the date you first accept this Agreement, or if you have not registered for an account, then within thirty (30) days following the date you first use our Services. If you don’t provide us with an Arbitration Opt-out Notice within the thirty (30) day period, you will be deemed to have knowingly and intentionally waived your right to litigate any Dispute except as expressly set forth in clauses (i) and (ii) above. The exclusive jurisdiction and venue of any IP Protection Action or, if you timely provide us with an Arbitration Opt-out Notice, will be the state and federal courts located in Oregon and each of the parties hereto waives any objection to jurisdiction and venue in such courts. Unless you timely provide us with an Arbitration Opt-out Notice, you acknowledge and agree that you are each waiving the right to a trial by jury or to participate as a plaintiff or class member in any purported class action or representative proceeding. Further, unless you otherwise agree in writing, the arbitrator may not consolidate more than one person’s claims, and may not otherwise preside over any form of any class or representative proceeding. If a decision is issued stating that applicable law precludes enforcement of any limitations set forth in this Agreement to Arbitrate on the right to arbitrate claims on a class or representative basis, or as part of a consolidated proceeding, as to a given claim for relief, then that claim (and only that claim) must be severed from the arbitration and brought in the state or federal courts located in Oregon. All other claims will be arbitrated. This “Dispute Resolution” section will survive any termination of this Agreement.
The arbitration will be administered by the American Arbitration Association (“AAA”) in accordance with the Commercial Arbitration Rules and the Supplementary Procedures for Consumer Related Disputes (the “AAA Rules”) then in effect, except as modified by this “Dispute Resolution” section. (The AAA Rules are available at https://www.adr.org/Rules or by calling the AAA at 1-800-778-7879.) The Federal Arbitration Act will govern the interpretation and enforcement of this Section.
A party who desires to initiate arbitration must provide the other party with a written Demand for Arbitration as specified in the AAA Rules. AAA provides a general form for a Demand for Arbitration and a separate form for Demand for Arbitration for Oregon residents. The arbitrator will be either a retired judge or an attorney licensed to practice law and will be selected by the parties from the AAA’s roster of arbitrators. If the parties are unable to agree upon an arbitrator within seven (7) days of delivery of the Demand for Arbitration, then the AAA will appoint the arbitrator in accordance with the AAA Rules.
ARBITRATION LOCATION AND PROCEDURE
Unless you agree with us otherwise, the arbitration will be conducted in the county where you reside. If your claim does not exceed $10,000, then the arbitration will be conducted solely on the basis of the documents that are submitted to the arbitrator, unless you request a hearing or the arbitrator determines that a hearing is necessary. If your claim exceeds $10,000, your right to a hearing will be determined by the AAA Rules. Subject to the AAA Rules, the arbitrator will have the discretion to direct a reasonable exchange of information by the parties, consistent with the expedited nature of the arbitration.
The arbitrator will render an award within the time frame specified in the AAA Rules. The arbitrator’s decision will include the essential findings and conclusions upon which the arbitrator based the award. Judgment on the arbitration award may be entered in any court having jurisdiction thereof. The arbitrator’s award of damages must be consistent with the terms of the “Limitation of Liability” section above as to the types and amounts of damages for which a party may be held liable. The arbitrator may award declaratory or injunctive relief only in favor of the claimant and only to the extent necessary to provide relief warranted by the claimant’s individual claim. If you prevail in arbitration you will be entitled to an award of attorneys’ fees and expenses to the extent provided under applicable law. We will not seek, and hereby waive all rights we may have under applicable law to recover, attorneys’ fees and expenses if we prevail in arbitration.
Your responsibility to pay any AAA filing, administrative and arbitrator fees will be solely as set forth in the AAA Rules. However, if your claim for damages does not exceed $75,000, we will pay all such fees unless the arbitrator finds that either the substance of your claim or the relief sought in your Demand for Arbitration was frivolous or was brought for an improper purpose (as measured by the standards set forth in Federal Rule of Civil Procedure 11(b)).
Notwithstanding anything to the contrary in this Agreement, if we change this “Dispute Resolution” section after the date you accepted this Agreement or access our Services, you may reject any such change by sending us written notice (including by email to firstname.lastname@example.org) within 30 days of the date such change became effective, as indicated in the “Effective Date” listed at the beginning of this Agreement or in the date of our email to you notifying you of such change. By rejecting any change, you are agreeing that you will arbitrate any Dispute between you and us in accordance with the provisions of this “Dispute Resolution” section as of the date you accepted this Agreement, or accessed our Services.
12. General Provisions
This Agreement, including the Consent to Treatment via Telehealth and the Code of Conduct for Patients, make up the entire agreement relating to your use of the Medical Services, and supersede all prior agreements relating to the subject matter hereof.
We may change, suspend, or discontinue any of the Medical Services at any time. We will try to give you prior notice of any material changes to the Medical Services. We will not be liable to you or to any third party for any modification, suspension or discontinuance of the Medical Services.
This Agreement do not confer any third-party beneficiary rights. You may not transfer any of your rights or obligations under this Agreement to anyone else without our consent. Brave Care may assign its rights in connection with a merger, acquisition, or sale of assets, or by operation of law or otherwise.
Even after termination, this Agreement will remain in effect such that all terms that by their nature may survive termination will survive such termination.
If you have any questions about this Agreement, please contact email@example.com.
BY SIGNING BELOW, I ACCEPT THE CONTENTS OF THIS AGREEMENT.
Code of Conduct for Patients
To provide a safe and healthy environment for staff, visitors, patients and their families, Brave Care expects visitors, patients and accompanying family members to be respectful members of our community. Please refrain from unacceptable behaviors that are disruptive or pose a threat to the rights or safety of other patients and staff.
As a patient or patient family member visiting our clinic, please consider the following:
- If you have any questions about the care you or your child receive, or are unhappy with the service received in our office, please contact our Head of Clinical Operations before you leave our office so that any clarifications about your care or the services you received can be addressed. If the Head of Clinical Operations is not available then the Manager-On-Duty can assist you.
- Please communicate all issues that you wish to discuss with the provider at the time your appointment is scheduled, so that an appropriate amount of time can be allotted. Please note that follow-up visits are sometimes necessary to make sure that we provide the best care possible for you and your child and can give adequate time to all of your concerns.
- Questions about your billing can be addressed by contacting our billing vendor, Apero Health, at 503-212-0747.
- Please be courteous with the use of your cell phone and other electronic devices. When interacting with any of our staff, please put your devices away. Set the ringer to vibrate before storing away.
- Recording or videoing of conversations is prohibited without the express permission of all staff being recorded and the ability to protect all other patient information in the surrounding area.
- Adults must supervise their children at all times.
Brave Care reserves the right to discharge any patient not following this Code of Conduct for reasons including, without limitation:
- Possessing firearms or any weapon on Brave Care property
- Intimidating or harassing staff or other patients
- Making threats of violence through phone calls, letters, voicemail, email or other forms of written, verbal or electronic communication
- Physically assaulting or threatening to inflict bodily harm
- Making verbal threats to harm another individual or destroy property
- Damaging business equipment or property
- Making menacing or derogatory gestures
- Making racial or cultural slurs or other derogatory remarks
- Smoking within 10 feet of any entrance to our clinics or within 10 feet of any staff member or other patient.
- Use of inappropriate language with a member of our care team or within earshot of other patients or families.
- Refusing to follow office rules regarding sanitation and infectious disease prevention.
If you are subjected to any of these behaviors or witness inappropriate behavior, please report to any staff member. Violators are subject to removal from the facility and/or discharge from Brave Care.