Terms and Conditions

I acknowledge and understand that I am voluntarily becoming a member of Knight & Gayles Health Care; (herein Knight & GaylesMD) and that this agreement is non-transferable. I acknowledge and understand that this agreement does not provide comprehensive health insurance coverage nor is it a contract of insurance and that this agreement only provides access to health care services.

I further agree that Knight & GaylesMD has recommended, either through verbal expression or disclaimer on its website, advertisements, and or written materials, that members maintain insurance coverage for major medical, hospitalizations, specialized, and/or complex care, emergencies, and or serious illnesses.

 

I acknowledge and understand that I am responsible for any charges incurred for health care services performed outside of and in addition to those offered with Knight & GaylesMD including but not limited to emergencies hospital and specialty services and that Knight & GaylesMD will not bill or seek reimbursement from insurance carriers for any services provided by Knight & GaylesMD.

I acknowledge and understand that Knight & GaylesMD providers will 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 understand and acknowledge that this policy is available for my review at any time at each Knight & GaylesMD practice, online at www.KgCare.com.

AutoPay I acknowledge and agree to pay my monthly membership fee in advance, on or before its due date either by enrolling in autopay or receiving monthly invoices if applicable. By enrolling in autopay, I have authorized Knight & Gayles to obtain my payment each month, in advance for the following month of services by direct transfer of funds from my selected financial institution including debit or credit card account. You have the right to decline such authorization by selecting "Cancel" or not enrolling in autopay. If you select "Cancel" or decide not to enroll in autopay, future, and recurring ACH/EFT transactions will not be scheduled and you will be responsible for taking the appropriate action to pay your membership fees.

If your financial institution (bank, credit card company or other) refuses payment for insufficient funds, closed or unauthorized accounts, or any other reason, you will be charged our late/non-sufficient fund charge for each failed attempt made in addition to any charges your financial institution may assess. If initially rejected, Knight & Gayles will make additional, multiple attempts to execute the ACH/EFT transaction for up to 3 days following the initial refusal. At the end of the 3 day period, if there has not been a successful transfer, your ACH/EFT authorization will be terminated. You have the right to revoke your Auto Pay enrollment at any time, and you can do so by contacting us at 888-310- 4674 and requesting an AutoPay Termination form. Any revocation of your authorization will not take effect until after receipt of your request in writing on Auto Pay Termination form which will then result in the discontinuance of your Auto Pay authorization, at which time you will be responsible for taking appropriate action to pay your membership fee. You must notify Knight & Gayles of any change in your checking or savings account information and complete another AutoPay authorization form to have your Membership fee paid using any new debit or credit card, checking or savings account information. You may obtain a new AutoPay authorization form by contacting us at 888-310-4674.

 

Knight & Gayles will send your monthly statement to you in electronic form, at least 5 days prior to your payment due date. The amount shown as due will constitute notice to you of any variance in amount from the amount paid in the previous month. The balance shown as due on your statement view will be deducted on the payment due date. By participating in the AutoPay service, you are representing that you are the authorized user of any debit card, credit card, or bank account used to make payment to Knight & Gayles.

Knight & Gayles reserves the right to terminate your participation in this service for any reason, including but not limited to late payment, non-payment, or fraudulent payments. Notification of any such termination will be done through your email address currently listed in our records

If I, member-elect to discontinue auto pay, I agree that I will be subject to an additional fee per month in addition to monthly membership. In the event that I am unable to pay on time, either through Auto Pay, or other methods, I understand that I will be charged a $15 late fee in addition to my monthly past due balance and I acknowledge that my Membership Agreement may be terminated.

Communications You consent to accept and receive communications from us, including e-mail, text messages, calls, and push notifications to the cellular telephone number and or email you provide to us. These communications may be generated by automatic telephone dialing systems which will deliver prerecorded messages, including for the purposes of secondary authentication, receipts, reminders and other notifications. Standard message and data rates applied by your cell phone carrier may apply to the text messages we send you. You may opt-out of receiving communications by following the unsubscribe options we provide to you.

 

You may also opt-out of text messages from Knight & Gayles at any time. You acknowledge that opting out of receiving communications may impact your use of the Services.

Payment: We may use and disclose your health information to bill and collect payment from you or, as applicable, your employer, for services you received. I acknowledge and understand that I may terminate this Membership Agreement at any time and for any reason by providing written notice to Knight & GaylesMD. Monthly fees will continue to accrue until written termination notice is received. Pre-paid fees will be prorated to the date Knight & GaylesMD has received my written termination and refunded to me within sixty (60) business days. In addition, I acknowledge and understand that Knight & Gayles may terminate this Member Agreement by providing me written notice. Pre-paid monthly fees will be prorated to the date of termination and refunded to me within sixty (60) business days. Knight & Gayles will not terminate this Patient Agreement solely on the basis of health status. I acknowledge and understand that Knight & GaylesMD may add or discontinue services or may increase its rates and or associated fee at any time (but no more than once per year), and that I will be given, in writing, at least sixty (60) days notice of such rate or fee changes.

 

I acknowledge and understand that if I am enrolled in Medicare I will receive a Medicare Opt-Out Agreement for review and signature before my first appointment. This Agreement does not prevent me from receiving current or future Medicare benefits from other providers; neither Knight & GaylesMD, its provider(s), nor I will seek reimbursement from Medicare for the medical services received under this agreement. Rights & Responsibilities I understand that I have the right to choose or change my Knight & GaylesMD provider at any time, for any reason. I understand that all reasonable efforts will be made to accommodate my request, but my request is subject to provider availability.

 

In order to receive the best possible care from my Knight & GaylesMD provider(s), I agree to be actively involved in my health care decisions and to disclose all relevant information so they can help me achieve my health goals. I also agree to inform my provider(s) of any healthcare services I receive outside of Knight & GaylesMD (such as emergency room, specialist, or hospital services). I understand that I have the right to receive accurate and easily understood information about Knight & GaylesMD services, health care professionals, affiliates, and facilities. If I fluently speak a language different from that of my clinician or staff, have a physical or mental disability, and or do not understand the information being provided, I understand that Knight & GaylesMD will make its best effort to provide assistance so I can make informed health care decisions. If I require interpreter services beyond what can be provided by Knight & GaylesMD, professional interpreters may be provided at an additional cost to me. Individuals whom I designate may represent or speak for me if I cannot make my own decisions. I understand that I have the right to speak in confidence with my Knight & GaylesMD provider(s) and to have my health care information protected. I understand that Knight & GaylesMD and its providers will not disclose my information without my authorization or without a legal obligation to do so. I also understand that I have the right to review and receive a copy of my personal medical record and may request that my Knight & GaylesMD provider(s) amend my record if I feel it is inaccurate or incomplete by contacting the appropriate provider. I understand that I have the right to know of my treatment options and to participate in my health care decisions. I further understand and agree that portions of my care may be provided by medical professionals, such as a Physician Assistant, Nurse Practitioner, Registered Nurse, or Medical Assistant, therapist, counselors and or others appropriately trained, licensed and in good standing but as required supervised and or under the direction of a licensed Physician.

In the event of membership termination, I understand that I must complete a written service cancellation form. Any differences in prepayment of services and the date of cancellation will be refunded to me. Refunds are not issued for months in which any service has been rendered either in person, via email, text, telemedicine, or otherwise. I understand that if my account is overdue, I am responsible for resolving the outstanding balance prior to receiving further service, or my service is subject to cancellation.

 

I understand that I have the right to considerate, respectful, and nondiscriminatory care from my Knight & GaylesMD provider(s). I also understand that I am responsible for communicating clearly and respectfully with my provider(s). Should I become dissatisfied with my care, I agree to notify Knight & GaylesMD immediately so my concerns may be addressed in a timely manner. I understand that I have the right to a fair, fast and objective review of any complaint I have against my provider(s) or any other staff including complaints about hours of operation, the conduct of personnel, practices, and adequacy of health care services. I agree to first bring any complaints to the attention of Knight & GaylesMD staff and to participate in the Knight & Gayles complaint and grievance process. Unresolved complaints may be brought to the attention of the Board of Healing Arts in the State of providers residency. A complaint form is available and can be completed and emailed to the governing board or printed and mailed to the address of the Board of Healing Arts in the State of providers residency. All complaints must be received in writing or electronically. I understand that I am responsible for not exposing my Knight & GaylesMD provider, staff, others, or myself to disease or danger. I understand that I can receive information from my Knight & GaylesMD provider(s) about protecting the health and safety of my providers, others, and myself.

Membership Agreement Knight & Gayles Health Care, herein referred to as Knight & GaylesMD, provides memberships for access to routine, primary care services. These memberships are not insurance and cannot be used for any hospitalization, catastrophic, complex, or specialist care. Membership permits you access to routine primary care, by methods including but not limited to, in person, video-conference (telemedicine), email, telephone, text, and secure messaging. Your membership provides you access to receive such services rendered by a licensed, in good standing health care professional in the State of {Residency}. You also agree to receive and or that portions of the services you receive may be delivered by a medical professional including but not limited to Physician Assistants, Nurse Practitioner, Registered Nurses, Therapist, Counselors, or other medical professional competently trained, in good standing and licensed to provide such service, under the supervision of, or collaborating with a licensed Physician where required. This Member Agreement provides access to primary care medical services by providers either employed or contracted by Knight & GaylesMD. A detailed description of such services shall be represented in written format by means of retainer or medical agreement between the provider and individual member and or members’ legal guardian. Member understands and agrees that no other services shall be accessed, covered, or rendered by provider except as agreed upon and described within that retainer or medical agreement.

Knight & Gayles Health Care has no influence, persuasion, say so, or determination of medical services provided, treatments, or procedures rendered or delivered whether by an employed or contracted provider. Providers, in their sole discretion, in relation to their training, judgment, knowledge, scope of practice, and expertise are responsible for the medical care, treatments, procedures, advice, counsel, and or recommendations to members. This membership does not cover lab work, diagnostic test, onsite distribution of prescriptions, or workman compensation-related procedures, except as detailed and expressed in written format by each provider via a retainer or medical agreement. Excluded services and their associated cost are available at each Knight & GaylesMD practice location.

Enrollment Knight & GaylesMD accepts enrollments regularly throughout the year; as access to providers are available, and includes compiling names, address, phone numbers, email address, and other contact information of future or potential members. Members who enroll and desire service during the current month will be charged the full or a prorated fee for that month of service. Members understand that accessing services and or providers will be limited until completion of initial appointment/Welcome Exam.

 

Privacy Policy Knight & GaylesMD respects your privacy and does not sell or disclose identifying information we collect through our website or services. The use of information collected through our website and or service shall be used to the purpose of providing the service for which you have engaged us. Referrals As a Member you will receive, as necessary, referrals to specialist, facilities, or other healthcare providers as deemed necessary by your Knight & GaylesMD provider(s); who in each instance will endeavor to comply with your insures network restrictions. In the event your insurer requires an enrolled or participating providers to make such referrals, Member agrees and understands that he/she is responsible for any and all charges associated with obtaining that referral.

 

Cancellation Policy Memberships can be canceled by requesting a Member Termination form online at www.Kgcare.com or by phone at 888- 310-4674. Membership cancellations must be received, in writing,  in order to stop your automatic withdrawal on for the following month. Membership access will terminate at the end of the current month for request received in a month where services have been rendered or received. Membership fees will not be prorated in a month where any service has been rendered in person, via email, text, telemedicine, or otherwise. Membership Cancellation Requests received after the 15th of the month may encounter charges for the following month of services, which will be refunded as suitable, except the rendering of services in person, via email, text, telemedicine, or otherwise. Reactivating Cancelled Membership: A canceled Membership can only be reactivated by paying the past due balance, late fee(s), and the current month of dues. Members who have existing balances, that re-join under another primary member or account must bring their past due balance current prior to receiving services. Knight & Gayles reserves the right to cancel membership at any time for any reasons, including if Member fails to allow Knight & Gayles the authority to withdraw/charge for monthly fee, falsification of identification or any misrepresentations.

TREATMENT/SERVICES EXCLUDED FROM MEMBERSHIP: a. Onsite distribution of prescriptions and or controlled substances unless otherwise agreed upon by physician b. Services that providers are incapable of providing in such settings due to lack of medical equipment or potential reduction of quality standards maintained as best practice. c. Member understands that the list below of excluded treatments or services is provided for example only and does not include all of the services that are excluded from coverage under the terms of their Membership. Excluded services include:  Life-threatening events such as gunshot wounds, heart attacks, and serious infections, hospitalizations and or treatment performed or ordered by other providers, special diagnostic labs, MRI’s, and other complex procedures, and or treatments that are not capable of being provided due to lack of proper medical equipment, training, staff, or scope of practice. Same limitations apply to non-members including urgent care services– where applicable, physical and occupational therapy, chronic pain management, psychiatric emergency management, work-related injuries and other workers compensation services, and any emergency care that should, in the best interest of the Member, be provided at or by another more capable provider or facility.

UNENFORCEABLE TERMS: o If any provision of these Terms and Conditions of Membership is held invalid, illegal, or unenforceable, these Terms and Conditions of Membership will be interpreted as if such provision, to the extent the same has been held invalid, illegal, or unenforceable, had never been contained herein. 17. SUCCESSORS: o These Terms and Conditions of Membership shall be binding upon and inure to the benefit of the parties hereto and their respective heirs, successors, or executors. 18. NOTICES: o Any notice required or allowed to be given shall be addressed to the other party at the address on file or public record or to such other address as either party may instruct the other party in writing in accordance with this Section.

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This is not health insurance. We encourage members to maintain adequate medical and prescription coverage.