Patient Services Agreement


This is an Agreement entered into on , 20 , between J. Timothy Ames, MD, PC, an Indiana Professional Corporation (Clinic, Us or We), and
(Patient or You).


The CLINIC is a Direct Pay primary care practice (DPC), which delivers primary care services through its physician, Dr. J. Timothy Ames (Physician), at 3176 Lancer Street, Portage, Indiana 46368. In exchange for certain fees, the CLINIC, agrees to provide You with the Services described in this Agreement on the terms and conditions contained in this Agreement.


1. Patient. In this Agreement, “Patient” means the persons for whom the Physician shall provide care, and who have signed this agreement or are listed on the document attached as Appendix 1, which is a part of this agreement.

2. Services. In this Agreement, “Services”, means the collection of services, offered to you by US in this Agreement. These Services are listed in Appendix 1, which is attached and a part of this Agreement.


3. Term. This Agreement will last for one year, starting on ____ _______.

4. Renewal. The Agreement will automatically renew each year on the anniversary date of the agreement, unless either party cancels the Agreement by giving 30 days written cancellation notice.

5. Termination. Regardless of anything written above, You always have the right to cancel this agreement. Either party can end this agreement at any time by giving the other party 30 days written notice.

6. Fees. In exchange for one year of Services (listed in in Appendix 1), You agree to pay US, a fee in the amount that appears Appendix 3, attached. This fee is payable when you sign the Agreement, and on the first business day of each month thereafter. Patient has the option to pay through automatic credit card payment. If this Agreement is cancelled by You or by US before the Agreement ends, WE will review your account, and depending on the circumstances, WE will settle your account in one of the following ways:

(a) WE will account for your fees on a per diem basis; but

(b) If the amount remaining in your account after making a per diem refund, is less than the fair market value (Value) of Services that you received, Your refund will instead consist of the amount remaining in your account after deducting the Value of the service you received; or

(c) If Value of the services delivered to the patient up to the time of cancellation exceeds the amount paid in membership fees, You will compensate the CLINIC in the amount of the excess. The Parties agree that fair market value is the equal to the CLINIC’s usual and customary fees if billing on a fee for service basis. A copy of these fees is available on request and is also available at the CLINIC for your review.

7. Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that that neither the CLINIC, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patients. We make no representations that any fees that You pay under this Agreement are covered by your health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan and to submit any required billing. ______ (Initial)

8. WE CANNOT Accept Medicare Patients. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that at this time, Medicare Patients are not eligible to be treated by the CLINIC or its Physician, and Medicare cannot be billed for any services performed by the same. Therefore, Patient acknowledges that s/he is neither a Medicare beneficiary nor Medicare eligible. The Patient agrees that if s/he will become eligible during the term of this Agreement, s/he will notify the CLINIC within 60 days of becoming eligible and this agreement will be terminated upon Medicare eligibility. Any excess fees will be refunded to Patient, and the CLINIC will make every effort to provide the Patient with names and contacts for primary care alternatives. ______ (Initial)

9. This Is Not Health Insurance. Your initials on this clause of the Agreement acknowledges Your understanding that this Agreement is not an insurance plan or a substitute for health insurance. You understand that this Agreement does not replace any existing or future health insurance or health plan coverage that You may carry. The Agreement does not include hospital services, or any services not personally provided by the CLINIC, or its employees. You acknowledge that the CLINIC has advised You to obtain or keep in full force, health insurance that will cover You for healthcare not personally delivered by the CLINIC, and for hospitalizations and catastrophic events. ______ (Initial)

10. Communications. The Patient acknowledges that although Clinic shall comply with HIPAA privacy requirements, communications with the Physician using e-mail, facsimile, video chat, cell phone, texting, and other forms of electronic communication can never be absolutely guaranteed to be secure or confidential methods of communications. As such, Patient expressly waives the Physician’s obligation to guarantee confidentiality with respect to the above means of communication. Patient further acknowledges that all such communications may become a part of the medical record.

By providing an e-mail address on the attached Appendix 2, the Patient authorizes the CLINIC, and its Physicians to communicate with him/her by e-mail regarding the Patient’s “protected health information” (PHI). The Patient further acknowledges that:

(a) E-mail is not necessarily a secure medium for sending or receiving PHI and, there is always a possibility that a third party may gain access;

(b) Although the Physician will make all reasonable efforts to keep e-mail communications confidential and secure, neither the CLINIC, nor the Physician can assure or guarantee the absolute confidentiality of e-mail communications;

(c) At the discretion of the Physician, e-mail communications may be made a part of Patient’s permanent medical record; and,

(d) You understand and agree that e-mail is not an appropriate means of communication in an emergency, for time-sensitive problems, or for disclosing sensitive information. In an emergency, or a situation that You could reasonably expect to develop into an emergency, You understand and agree to call 911 or the nearest Emergency room, and follow the directions of emergency personnel.

(e) Email Usage. If You do not receive a response to an e-mail message within 24 hours, You agree that you will contact the Physician by telephone or other means.

(f) Technical Failure. Neither the CLINIC, nor the Physician will be liable for any loss, injury, or expense arising from a delay in responding to Patient, when that delay is caused by technical failure. Examples of technical failures (i) failures caused by an internet service provider, (ii) power outages, (iii) failure of electronic messaging software, or e-mail provider (iv) failure of the CLINIC’s computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of e-mail communications by a third party which is unauthorized by the CLINIC; or (v) Patient failure to comply with the guidelines for use of e-mail described in this Agreement.

11. Change of Law. If there is a change of any relevant law, regulation or rule, federal, state or local, which affects the terms of this Agreement, the parties agree to amend this Agreement to comply with the law.

12. Severability. If any part of this Agreement is considered legally invalid or unenforceable by a court of competent jurisdiction, that part will be amended to the extent necessary to be enforceable and the remainder of the contract will stay in force as originally written.

13. Reimbursement for services rendered. If this Agreement is held to be invalid for any reason, and the CLINIC is required to refund fees paid by You, You agree to pay the CLINIC an amount equal to the fair market value of the medical services You received during the time period for which the refunded fees were paid.

14. Amendment. No amendment of this Agreement shall be binding on a party unless it is in writing and signed by all the parties. Except for amendments made in compliance with Section 11, above.

15. Assignment. This Agreement, and any rights You may have under it, may not be assigned or transferred by You.

16. Legal Significance. You acknowledge that this Agreement is a legal document and gives the parties certain rights and responsibilities. You also acknowledge that You have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.

17. Miscellaneous. This Agreement shall be construed without regard to any rules requiring that it be construed against the party who drafted the Agreement. The captions in this Agreement are only for the sake of convenience and have no legal meaning.

18. Entire Agreement. This Agreement contains the entire agreement between the parties and replaces any earlier understandings and agreements whether they are written or oral.

19. No Waiver. In order to allow for the flexibility of certain terms of the Agreement, each party agrees that they may choose to delay or not to enforce or the other party’s requirement or duty under this agreement (for example notice periods, payment terms, etc.). Doing so will not constitute a waiver of that duty or responsibility. The party will have the right to enforce such terms again at any time.

20. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Indiana. All disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for the CLINIC in Portage, Indiana.

21. Service. All written notices are deemed served if sent to the address of the party written above or appearing in Appendix 2 by first class U.S. mail.

The parties may have signed duplicate counterparts of this Agreement on the date first written above.

J. Timothy Ames, MD, President,

Signature of Patient Name of Patient (printed)


1. Medical Services. As used in this Agreement, the term Medical Services shall mean those medical services that the Physician, himself is permitted to perform under the laws of the State of Indiana and that are consistent with his training and experience as a family medicine physician, as the case may be. The Patient shall also be entitled to an annual in-depth “wellness examination and evaluation,” which shall be performed by the Physician, and may include the following depending on the age, medical history and preference of the patient:

• Personalized Health Risk Assessment
• Vision and Hearing Screening
• Pulmonary Function Testing
• Psychosocial Screening
• Custom Wellness Plan to include recommendations for immunizations, additional screening tests/evaluations, fitness and dietary plans.
• The convenience of access to many commonly prescribed prescription medications at greatly reduced prices, dispensed on premises.

2. Non-Medical, Personalized Services. The CLINIC shall also provide Patient with the following non-medical services (“Non-Medical Services”):

(a) After Hours Access. Patient shall have direct telephone access to the Physician seven days per week. Patient shall be given a phone number where patient may reach the Physician directly for guidance regarding concerns that arise unexpectedly after office hours. Video chat may be utilized when the Physician and Patient agree that it is appropriate.

(b) Physician Absence From time to time, due to vacations, illness , or personal emergency, the Physician may be temporarily unavailable to provide the services referred to above in this paragraph one. In order to assist Patients in scheduling non-urgent visits, the Clinic will notify Patients of any planned Physician absences as soon as the dates are confirmed. In the event of the Physician’s unplanned absences, Patient’s will be given the name and telephone number of an appropriate physician for the Patient to contact. Any treatment rendered by the substitute physician is not covered under this contract, but may be submitted to Patient’s health plan.

(c) E-Mail Access. Patient shall be given the Physician’s e-mail address to which non-urgent communications can be addressed. Such communications shall be dealt with by the Physician or staff member of the CLINIC in a timely manner. Patient understands and agrees that email and the internet should never be used to access medical care in the event of an emergency, or any situation that Patient could reasonably expect may develop into an emergency. Patient agrees that in such situations, when a Patient cannot speak to Physician immediately in person or by telephone, that Patient shall call 911 or the nearest emergency medical assistance provider, and follow the directions of emergency medical personnel.

(d) No Wait or Minimal wait Appointments. Reasonable effort shall be made to assure that Patient is seen by the Physician immediately upon arriving for a scheduled office visit or after only a minimal wait. If Physician foresees a minimal wait time, Patient shall be contacted and advised of the projected wait time.

(e) Same Day/ Next Day Appointments. When Patient calls or e-mails the Physician prior to noon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort shall be made to schedule an appointment with the Physician on the same day. If the patient calls or e-mails the Physician after noon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort shall be made to schedule Patient’s appointment with the Physician on the following normal office day. In any event, however, the CLINIC shall make every reasonable effort to schedule an appointment for the Patient on the same day that the request is made.

(f) Visitors. Non-Medicare family members temporarily visiting a Patient from out of town may, for a two-week period, take advantage of the services described in subparagraphs (a), (c), and (d) of this paragraph. Medical services rendered to Patient’s visitors shall be charged on a fee-for-service basis.

(g) Specialists Coordination. The CLINIC and Physician shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the CLINIC Physician.


Annual fees as set out below shall apply to the following Patient(s), who by signing below agree to the terms and conditions of the J. TIMOTHY AMES, MD, PC Medical Agreement Form.

Printed Name Date of Birth (MM/DD/YYYY) Age

Street Address City, State, Zip

Home Phone Work Phone Cell Phone Preferred email

Spouse Name Date of Birth (MM/DD/YYYY) Age

Home Phone Work Phone Cell Phone Preferred email

Child/Children to Whom this Agreement Applies:

Print Name Date of Birth (MM/DD/YYYY) Age

Print Name Date of Birth (MM/DD/YYYY) Age

Print Name Date of Birth (MM/DD/YYYY) Age

Print Name Date of Birth (MM/DD/YYYY) Age

Preferred Payment Method*
□ Yearly (Credit/Debit Card)
□ Monthly (Credit/Debit Card, charged on the first business day of each month/ Check)
□ Employer
*All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement.

I certify that I have read, understand, and agree to the terms set forth in the J. TIMOTHY AMES, MD, PC Medical Agreement Form. I further certify that I have received a copy of this form.


0-18 years of age $20 per month*

19-50 years of age $50 per month

51+ years of age $75 per month

*With the enrollment of at least one adult. You will be charged $20 per month, per child for the first two children. There is no fee for any additional children under the age of 18 and living in the same household.

Patient 1 $
Patient 2
Additional Patients