Terms

  • I acknowledge and understand that I am voluntarily becoming a MorningStar Family Health Center (MSFHC) membership patient and that this agreement is non-transferable.
  • I have reviewed the MSFHC Patient Services Guide and I have had the opportunity to ask questions and receive answers regarding its content.
  • I acknowledge and understand that this agreement does not provide comprehensive health insurance coverage nor is it a contract of insurance and that it only provides the health care services specifically described in the Patient Services Guide.
  • I acknowledge and understand that I am responsible for any charges incurred for health care services incurred outside of MSFHC including but not limited to emergency room, hospital, outside laboratory, imaging and specialty services.
  • I acknowledge and understand that MSFHC must maintain a record of my health information and must protect the privacy of my health information as per the terms of the Notice of Privacy Practices.
  • I acknowledge and agree to pay my monthly fee on a monthly basis by recurring debit of my credit card or bank account. I understand I will be charged a $20 fee for returned charges and that my service agreement may be terminated.
  • I acknowledge and understand that I may terminate this Patient agreement at any time after the first 3 months and for any or for no reason by providing written notice to MSFHC. Monthly fees will continue to accrue until written termination notice is received. Cancellation will take effect at the end of the current monthly billing cycle. I acknowledge and understand that a $250 reenrollment fee will apply if I choose to re-enroll.
  • I authorize the practice to email and text me to exchange non-medical information. I understand that this allows the practice to serve me more efficiently. I understand I made terminate this authorization at any time.
  • In addition, I acknowledge and understand that MSFHC may terminate this Patient Agreement by providing me written notice. MSFHC will not terminate solely on the basis of health status.
  • I acknowledge and understand that MSFHC may add or discontinue services or may increase my fee schedule at any time (but not more than once per year) and that I will be given notice at least 60 days of such fee schedule changes.
  • I acknowledge that if I am enrolled in Medicare, I may not be a Full Member, but may be a Supporting Member. The Supporting Membership only covers services NOT covered by Medicare. We are Medicare participating and will electronically submit your claims to Medicare and your secondary insurance.