2026 Retainer Medical Practice Agreement for a Direct Primary Care Practice:

Resolute Integrative Health LLC

 

This is an Agreement, dated this ____ day of __________________, 202___, between Resolute Integrative Health LLC (“Resolute” or “Practice”), an Oregon Limited Liability Company located at 216 E Main Street, Rogue River, OR 97537, Heather Friend, DNP, APRN, FNP-C (“Practitioner”) in her capacity as an agent of Resolute and you, _________________________________________(“Patient”). 

 

Background

 

Resolute provides primary care and integrative medical services for a simple monthly fee. We focus on whole-person health. Learn more at www.ResoluteIntegrativeHealth.com

 

Definitions and Agreements

 

1. Patient. Any person receiving Services who signs or is listed in this contract.

 

1. Services. A defined package of primary care and related amenities, and/or integrative services as set forth in Appendices 1 and 2. 

• Fee Schedule and Cancellation Policy

• Semi-Annual Membership Agreement

1. 1. 1. Membership begins upon receipt of enrollment fee/first month’s dues. Contract renews automatically every six months unless cancelled. The Patient authorizes automatic recurring monthly billing to stored payment method(s). Current rates appear in Appendices 1 and 2 and are subject to applicable taxes. Fee adjustments may occur at renewal with ≥30 days’ written notice and right to cancel. 

 

Payment Failure. If payment is declined, alternative payment methods may be charged. If the account remains delinquent, services may be suspended. Late fees ($50 after 14 days) apply; accounts >30 days overdue are subject to dismissal unless payment plan is arranged. Failure to pay for retainer services rendered will result in collections acquisition after 30 days overdue without a documented plan.

• Cancellation Policy

1. 1. Patients may cancel anytime in writing. Initial enrollment and first month fees are non-refundable. If cancelled less than 30 days from enrollment, the 6-month term is void. After 30 days, early cancellation triggers a charge equal to 50% of remaining contract balance. Services continue through the end of current billing month. All prescriptions beyond 30 days are discontinued. Returning patients after cancellation pay a re-enrollment fee equal to four months of dues.

 

1. Complex medical needs, integrative support, and wellness Add-ons. Resolute offers different membership tiers and “Add-ons” (such as functional medicine consults, hormone therapy, weight management, advanced supplement reviews, complex medical care). These services exceed typical primary care requiring more time, Practitioner education and experience. These incur separate charges and monthly fees (see Appendix 3). Some treatment recommendations may involve off-label use of medications or non-FDA-approved therapies. Participation is voluntary. Patients are encouraged to discuss risks and benefits with the Practitioner. No guarantee of outcome is made.

 

1. Non-Participation in Insurance. The Practice does not bill or submit claims to insurance, Medicare, or Medicaid including Oregon Health Plan. All Practitioners are opted in for orders and referrals for Medicare but have formally opted out of Medicare per federal law for claims. Patients cannot submit claims to Medicare or Medicaid. Medicare-eligible patients must sign Appendix 4 acknowledging no reimbursement will be sought. Patients understand that the Practice cannot submit orders or claims through Medicaid. Oregon Medicaid patients must sign Appendix 5 pursuant to OAR 410-120-1280 acknowledging this.

Notice. While Resolute does collaborate with some insurance plans, this Agreement is not health insurance and does not cover hospital or specialty care. Patients should maintain separate insurance for catastrophic and specialist expenses. This clinic membership alone does not satisfy ACA requirements. The Practice does not work with MOST HMO’s regarding orders and referrals. All other Private Insurance plans and Medicare will still allow the Practice to submit referrals and orders. 

1. Afterhours and Urgent/Emergency Care. Resolute is available for routine and some urgent concerns but does not replace emergency services or higher level urgent care needs. In a medical emergency, dial 911. After-hours communication is available but not guaranteed and at Practitioner discretion based on urgency. We kindly ask that all non urgent communication (ie refill requests, nonurgent scheduling, or other non urgent discussion be reserved to business hours as all communication goes to the provider cell. Misuse of after-hours access for non urgent communication may incur fees or dismissal. 

 

1. Termination of Membership. Either party may terminate this Agreement at any time. Patients must provide ≥24-hour notice; The Practice will provide ≥30-day written notice and referral list to comply with Oregon patient-abandonment laws unless termination occurs within 30 days of new patient status or abuse to staff. Termination reasons include (but are not limited to):

• Non-payment of dues
• Fraud or misrepresentation
• Repeated non-adherence with treatment plans or controlled-substance policies
• Abusive behavior including verbal or threats to staff/patients
• Practice closure or capacity limitations
• Complexity of care requiring higher level of resources or treatment

This section ensures both parties – the Practice and the Patient – can manage their healthcare and business needs efficiently, maintaining the flexibility required in the direct primary care setting.

 

1. Privacy & Electronic Communications. Electronic communication (email, fax, video, messaging, text, phone) are prone to risks, and when using them, you may expose your Protected Health Information (PHI) to interception by unauthorized third parties. While Resolute endeavors to protect privacy and secures all communications with security measures, we cannot guarantee the confidentiality of these communications. The Spruce App is for routine communication messaging and our Patient Portal “Elation Patient Passport” is for patient chart access. These are recommended for secure communication to comply with Health Insurance Portability and Accountability Act (HIPAA) standards, and including those willing to sign HIPAA Business Associate Agreements. Should you initiate communication using a less secure platform and disclose PHI, you are hereby providing your consent for Resolute to respond to you using the same communication method. This consent serves as an acknowledgement of the potential risk associated with such communication methods and releases Resolute from any liability should your PHI be accessed by unauthorized third parties as a result of such communications. You agree to not hold Resolute, its Practitioners, or staff liable for any breaches of confidentiality that may occur as a direct result of your choice to communicate through less secure platforms. 

 

1. Severability. Invalid provisions shall be modified to comply with law without affecting the remainder.

 

1. Reimbursement for Services if Agreement is Invalidated. If this Agreement is found unenforceable and fees refunded, Patient owes the local fair-market value of services rendered.

 

1. Assignment. Patients may not transfer rights under this Agreement.

 

1. Jurisdiction and Dispute Resolution.  This Agreement is governed by Oregon law. Disputes shall first be resolved by good-faith negotiation within 60 days. If unresolved, they shall be submitted to binding arbitration through the Arbitration Service of Portland (ASP) in Medford, Oregon, per ASP Commercial Rules. Arbitrator decision is final and enforceable in court. Prevailing party may recover reasonable attorney fees and costs. Either party may seek temporary injunctive relief in state or federal court (Jackson County, OR). The language shall be in English. This clause shall not preclude parties from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction. 

• Patient Understandings (initial each):

By initialing each line, I confirm my understanding and agreement with the terms outlined above, contributing to a transparent and mutually respectful healthcare relationship with Resolute.

 

_____ This Agreement is for ongoing primary care and is NOT a medical insurance policy. 

 

_____ In an emergency, I will call 911. 

 

_____ Resolute will not submit or contest any insurance claim.

 

_____ Resolute does not routinely prescribe daily controlled substances. Possible exceptions: ADHD; Buprenorphine; Hormone Therapy; Weight loss. Practitioner reserves the right to decline any prescription. 

 

_____ I will address grievances with Resolute directly before external action.

 

_____ I understand this Agreement does not satisfy the ACA insurance requirements.

 

_____ My enrollment is voluntary.

 

_____ I am entitled to receive a copy of this Agreement.

 

_____ This Agreement is nontransferrable.

 

_____ I will treat staff respectfully.

 

_____ I will keep contact, payment, and insurance information current.

By signing below, the undersigned Patient (or Guardian) and Resolute acknowledge and affirm their full and complete agreement to the terms and conditions set forth in this Agreement, including appendices referenced herein. Each party affirms that they have read, understand, and voluntarily accept the obligations, rights, and responsibilities outlined in the Agreement and its appendices. 

 

Patient Name: ________________________________________________

 

Patient (or Guardian) Signature:__________________________________________Date: ______________

APPENDIX 1: Periodic & Enrollment Fees

 

Enrollment Dues: Patients pay a non-refundable enrollment fee/first month’s dues before scheduling. 

• New Patient One Time Enrollment Fee

• $150 for adults and $50 for minors for Basic Primary Care
• $150 to $350 for our Resolute Plus tiers.

 

Monthly Periodic Dues: Ancillary services like urinalysis, EKG, onsite testing, laceration, cryotherapy and more are included; outside labs, prescriptions, or advanced procedures incur cost notice before treatment. Annual screening labs (CBC, CMP, Lipids, TSH, A1C — $218 value) included for Basic plan, additional lab panels are offered for Resolute Plus+ Tier.

• Monthly basic membership plan: 

• $47 per month for minors under 18
• $97 per month for adults 18 to 64
• $127 per month for adults ages 65 and older
• $297 per month max for a family (2 married parents + legal child minors under 18).

• Monthly Resolute Plus+ plan: 

• $150 per month for adults 18 and older. 
• For those with higher complexity, needing more frequent appointments, or integrative services outside of typical primary care where more time is often needed. Resolute reserves the right to assign a tier based on need.

* When deciding if the basic membership is the right fit, we suggest considering how many appointments you will likely need in a given 3 month cycle. If you are going to routinely need or request an appointment more than once every 2-3 months, the Plus+ option is required to ensure we can serve you appropriately. We understand that sometimes we have seasons of higher needs (ie acute event) and that is an exception to this rule. 

** DISCOUNT: 5% off for people who pay a 6 or 12 month plan up front.

***Additional Specialized Medicine Add-on’s are case by case. 

Late / No-Show / Afterhours Policies

• Unscheduled walk-ins or repeated abuse of same-day access: $100 fee.
• Second and following No-Shows: $50 each.
• Repeated Cancellations less than 4 hours warning: $50.
• Repeated violations → possible dismissal.
• Afterhours care – Repeated misuse will result in additional fees. Afterhours visit: $100 and at discretion of Practitioner (rare and not guaranteed)

After-Hours Texting: Non-urgent after-hours messages will be answered in 24-48 business hours. Practitioner discretion applies; repeated misuse of after-hours contact for non urgent issues may incur fees or dismissal. All messages go to provider phones and we request common sense on timing of text messages/Spruce use.

 

Practitioner Availability: At least 14 days notice provided for known unavailability. In unforeseen circumstances, notice issued as promptly as feasible. Urgent coverage is arranged via partner DPC or electronic communication with our Practitioners. Practitioners may take off reasonable time for training and self care.

 

Acceptance of Patients:  Practice may decline new patients when capacity or medical scope and/or medical complexity limitations exist, consistent with federal and Oregon non-discrimination laws. For patients who are on routine controlled substances, unless prior agreements have been arranged with the provider, we are not able to offer medical services to this population due to complexity.

 

APPENDIX 2: Comprehensive Service Structure

Appendix 2 clarifies the scope of services under the monthly fee.

 

1. Primary Care Services Include: Routine and preventive visits, chronic condition management, care coordination, and standard in-office testing. Lists available at www.ResoluteIntegrativeHealth.com 
2. In-Office Procedures (included unless otherwise stated): Minor suturing, skin cryotherapy, lesion removal, EKG, UA, wet mount, wound care. Repeated or high-cost consumables may carry more charges.

 

1. Laboratory and Diagnostic Studies:  In-office labs offered at declared negotiated low-cost cash rates or insurance can be used at a higher rate. External collections may use insurance.

 

1. Pharmaceuticals: In-office pharmacy dispensed medications are sold at a discounted cash price. Outside pharmacies set their own prices; insurance may apply at external pharmacies.

 

1. Pathology / Radiology: Are ordered through the most economical facility; costs discussed prior to testing. In office pathology cash prices are set at cost per Oregon law. Insurance can be used.

 

1. Specialist Referrals and Hospital Services: Not covered in the Practice; Practitioner assists with navigation to specialists or hospitals, including ordering, referring, and submitting prior authorizations to insurance.

 

1. Vaccinations and Additional Services: Not provided onsite due to storage cost; patients directed to pharmacies / public health clinics to use insurance or cash pricing.

 

1. Wellness Add-ons: (e.g., IV therapy, supplements, PT, cosmetic procedures) offered as resources permit; pricing posted publicly. EVOLT Scanner is free for members once monthly. 

 

1. Functional Medicine Elements: Not included in primary care fee unless identified as typical primary care. Additional fees apply.

 

APPENDIX 3: Wellness Add-ons Description and Terms

 

Optional add-ons beyond routine primary care, billed separately.

Examples: Certain weight medications, frequent coaching, nutrition, or other therapies, hormone affiliated products and services by certified specialists, supplements, functional medicine programs (case by case)

Patients interested in any Wellness Add-ons should consult with their Practitioner to discuss suitability, potential benefits, and associated risks. 

Financial Terms: Pricing disclosed in advance. Not included in monthly dues.

FDA Approval and Recommendations:  Some add-ons may be off-label or not FDA-approved but never explicitly disapproved. Patients acknowledge responsibility to review status and consent voluntarily. 

Patient Acknowledgement: Patient accepts financial responsibility and confirms discussion of risks and benefits with Practitioner. Updates to add-on availability will be communicated to patients.

COMPLETE THIS IF YOU HAVE MEDICARE

APPENDIX 4: Understanding for Medicare Beneficiaries (The Patient)

This Appendix forms part of the Agreement between Resolute Integrative Health LLC (“Resolute” or “Practice”) and the undersigned Medicare Beneficiary (“Beneficiary”).

 

Patient Name:              ____________________________________________________________

 

Patient Address: ____________________________________________________________

 

Medicare ID #: ____________________________________________________________

 

Resolute has informed the patient or their legal representative that the Practitioners at Resolute have opted out of the Medicare program in compliance with Section 4507 of the Balanced Budget Act of 1997. Practitioners at Resolute are not excluded from Medicare under Sections 1128, 1156, or 1892 of the Social Security Act and are still opted in for orders and referrals. 

 

By Initialing below, the Beneficiary/Patient or their legal representative acknowledges understanding and agreement to the following terms:

 

_____ I will pay Resolute directly for services

 

_____ Medicare fee limits do not apply at Resolute 

 

_____ I will not submit any claim to Medicare

 

_____ Services at Resolute are not eligible for Medicare payment 

 

_____ I may receive Medicare-covered care elsewhere if I wish

 

_____ I understand Medi-Gap and supplemental plans may not cover these services 

 

_____ I am not in an emergency situation at time of signing this Agreement

 

_____  have received a copy of this Appendix

 

This Appendix serves to clarify the Medicare Beneficiary’s (Patient) position in relation to Medicare and the services provided by Resolute. By proceeding with this Agreement, the Beneficiary accepts the terms herein, acknowledging that Resolute’s services are provided outside of the Medication program.

 

Beneficiary Patient (or Legal Representative) Signature: _________________________________

 

Date: ____________________________ Name:  ___________________________________

A copy of this Appendix has been provided to the Beneficiary or their legal representative for their records and 

reference.

APPENDIX 5: OHA Medicaid Patients

     Pursuant to https://oregon.public.law/rules/oar_410-120-1280, specifically section 5(g) and 5 (A-C), see below: 

 

5 (g) The client has requested to privately pay for a covered service. In this situation, the provider may bill the client if the provider informs the client in advance of all of the following: 

 

5 (C) That the client knowingly and voluntarily agrees to pay for the covered service; 

5 (D) The provider documents in writing, signed by the client or the client’s representative, indicating that the provider gave the client the information described in section (5)(g)(A-C); that the client had an opportunity to ask questions, obtain additional information, and consult with the client’s caseworker or client representative; and that the client agreed to privately pay for the service by signing an agreement incorporating all of the information described above. The provider must give a copy of the signed agreement to the client. A provider may not submit a claim for payment for covered services to the Authority or to the client’s MCE or third-party payer that is subject to the agreement. 

The Patient and Resolute Practitioner acknowledge that the above statutory/administrative requirements have been met. The Patient is aware that it is recommended that they seek primary care with another Practice who takes their insurance. Accepting Patients with Medicaid at Resolute are on a case by case and usually related to augmenting their medical care. The Patient understands that our Practitioners cannot submit claims, orders, referrals, or prior authorizations through Medicaid/OHP.

 

Beneficiary Patient (or Legal Representative) Signature: _________________________________

 

Date: ____________________________ Name:  ___________________________________

A copy of this Appendix has been provided to the Beneficiary or their legal representative for their records and reference.