Financial policy.
Membership Agreement
1. Patient-Clinician Relationship.
By your signature, you acknowledge that you are voluntarily becoming a patient of Lifestyles by Noor LLC, and its medical group or affiliated clinician. As a Lifestyles by Noor LLC patient, those services described in Section 2 below will be made available to you pursuant to the terms of this Membership Agreement.
2. Lifestyles by Noor LLC Services.
Health Care Services: As a patient, you are eligible to receive a set of primary care, preventive care, and urgent care services as offered by your individual clinician from among those listed in our Detailed Service List (attached below, as Appendix A, and available at Lifestyles by Noor LLC or at your Lifestyles by Noor LLC clinic location). You are also eligible to receive mobile phone and email access and same or next-day appointments (pending availability). During the term of this Agreement, the Health Care Services provided by Lifestyles by Noor LLC may be subject to change by Lifestyles by Noor LLC from time to time. Such changes, if any, shall be reflected on the Detailed Service List. All medical procedures are performed by appropriately licensed practitioners.
If you have a pre-existing medical condition, please contact us first to learn how you may benefit from Lifestyles by Noor LLC services. Pre-existing medical conditions do not disqualify you from enrolling in Lifestyles by Noor LLC’s service. Lifestyles by Noor LLC shall not decline to accept new patients solely because of the patient's health status. The Practice may, however, decline to accept a patient for cause, including, but not limited to: (a) The Practice has reached a maximum capacity; (b) The patient has previously contracted for services for which they have not paid; or (c) The patient's medical condition is such that the Practice is unable to provide the appropriate type of primary care services.
By entering into this Membership Agreement, you acknowledge that Lifestyles by Noor LLC does not provide health insurance coverage and that this is not a contract for insurance. Pursuant to New Hampshire RSA 329:1-E II. “a direct primary care agreement is not insurance and the primary care provider shall not be subject to the requirements of NH RSA 415 [Accident and Health Insurance], RSA 420 [Health Service Corporations], or the jurisdiction of the [State Insurance] Commissioner”, upon compliance with RSA 329:1-e.” Lifestyles by Noor LLC will not file any claims against the patient's health insurance policy or plan for reimbursement of any primary care services covered by this agreement.
This agreement is not workers' compensation insurance and does not replace an employer's obligations under NH RSA 281-A. Lifestyles by Noor LLC provides only the Health Care Services specifically described herein, and additional costs may be incurred for laboratory, medical imaging, surgery, specialist care, emergency department visits, and hospitalization required outside of Noor LLC’s services. Lifestyles by Noor LLC encourages you to combine Lifestyles by Noor LLC membership with appropriate health insurance coverage.
3. Fees & Payment
Lifestyles by Noor LLC charges the Membership Fee listed below per Member to include all Covered Healthcare Services included on the Detailed Services List.
● Lifestyles Pinnacle Membership $800.00 per month/$9,600.00 per year.
● Lifestyles Elevate Membership: $400.00 per month/$4,800.00 per year.
● Lifestyles Foundation Membership: $250.00 per month/$3,000 per year.
● Lifestyles Transformation Package: $5,500.00
● One Time Provider Consult: $750.00
● Founding Gold Membership: $399/month
● Well Woman GYN Membership: $125/month; $1,500/year
(a) Membership Fee. The Membership Fee for the Covered Healthcare Services of the above applicable membership/programs are due and payable in full upon enrollment unless a periodic, automated payment by the following payment method is determined at time of sign up. Payment options are:
____ Annually (full fee)
____Automatically deducted monthly payment of the monthly fee from the account of your choice.
Unless the Agreement is not renewed, the Patient will be billed for the Membership Fee for each Renewal Year prior to the beginning of each Renewal Year and the Patient agrees to pay the full invoiced Membership Fee or authorize one of the automated payment methods as indicated within 30 days after the date of invoice.
payable to “Lifestyles by NOOR.” (b) Refunds. Membership Fees are non-refundable.
A 10% discount will be applied to the total Membership Fee for annually pre-paid memberships.
Payment transactions declined due to insufficient funds or expired cards will result in an additional fee of $50, and failure to comply with payment terms may result in the termination of my membership. Services will not be rendered for patients with past-due accounts
Most, but not all, of the services described above in Section 2 are covered by the Membership Fee, subject to the limitations outlined in this Membership Agreement. However:
Per IRS guidance, if you participate in a high-deductible health plan with a health savings account (HSA) feature, you may be required to pay on a fee-for-service basis for certain primary care, non-preventive care, and urgent care services until such time as your deductible has been satisfied. If you don’t pay on a fee-for-service basis for these services, it is possible you may lose your ability to contribute to your HSA during your membership. Please consult your attorney or financial adviser. Lifestyles by Noor LLC hereby disclaims any responsibility or liability with respect to your decisions made thereto.
● Some Health Care Services provided by Lifestyles by Noor LLC are not covered by the Membership Fee (Non-Covered Health Care Services). The Lifestyles by Noor LLC Membership Fee schedule for these services will be provided to you upon your request. Lifestyles by Noor LLC may amend the Membership Fee schedule from time to time in its sole and absolute discretion and without prior notice.If you request and receive a Non-Covered Health Care Service, you can:
o Authorize Lifestyles by Noor LLC to submit a claim to be paid by your health plan (or other third party). Lifestyles by Noor LLC only submits claims for medication prior authorizations.
If you authorize Lifestyles by Noor LLC to submit a claim to be paid by your health plan or other third party, you hereby assign to Lifestyles by Noor LLC your rights to receive payment from any third party for the provision of Health Care Services by Lifestyles by Noor LLC. You acknowledge and agree that Lifestyles by Noor LLC may receive payments directly from any third party for the Non-Covered Health Care Services provided to you by Lifestyles by Noor LLC. You authorize Lifestyles by Noor LLC to release any information needed to determine benefits payable by a third party or their agents. In the event you receive any payment from a third party for a Non-Covered Health Care Service, you agree to turn over the payment in full to Lifestyles by Noor LLC.
You agree not to submit any claims to any third-party payor or any government health care program for Covered Services rendered by Lifestyles by Noor LLC to you under this Agreement.
All Membership Fees paid are non-refundable. This includes all Membership Fees that may have been paid whether such were paid on a monthly or annual basis.
Missed Appointment / Cancellation Fee. A fee of $375 will be charged for missed appointments or cancellations made with less than 24 hours' notice. This fee is separate from the Membership Fee and is not refundable or credited toward future Membership Fees.
4. Your Medical Information.
Your privacy is very important to us, and you control the use of your personal information. Lifestyles by Noor LLC has put important safeguards in place to make sure your medical information is protected and safe to maintain its confidentiality.
Lifestyles by Noor LLC seeks to work together with you to give you the best health care possible. Having access to your medical information will help your Lifestyles by Noor LLC health care professional give you the best possible care because he/she will have the most up-to-date information about your health. Therefore, as allowed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and to help us give you the right care in the right place and at the right time, your health plan and its contractors and agents (Health Plan) may electronically share with us your health-related information (including your “protected health information” as defined by HIPAA). Such shared health-related information may include things like visits to the doctor or hospital, medical conditions, current and past prescriptions, biometric data (height, weight, body fat percentage, etc.), and other health status-related information.
5. Digital Communications.
Unless advised otherwise in writing, you authorize Lifestyles by Noor LLC and its Practitioners and Practice staff and designees to communicate with Patient by Electronic Communication via the Practice’s patient portal regarding Patient’s protected health information (“PHI” as defined in the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations) via Patient’s cell phone and/or email address shown on this Agreement. Additionally, Patients will be able to communicate with the Practice via email regarding test results or any other non-urgent medical issues. Electronic Communication includes but is not limited to email, text (SMS, MMS, Instant Messaging), and audio or video conference chat. Patient acknowledges and agrees that:
(a) Electronic Communication may not be a secure medium for sending or receiving PHI;
(b) Although Practitioner and Practice staff will make reasonable efforts to keep Electronic Communication with Patient confidential and secure, Patient understands that they cannot assure or guarantee the confidentiality of Electronic Communication;
(c) At the discretion of Practitioner, Electronic Communication may be made a part of Patient’s permanent medical record;
(d) Patient will not use Electronic Communication for communications regarding emergency and/or urgent medical problems, or other time-sensitive issues. In the event of an emergency, or a situation in which the Patient could reasonably expect to develop into an emergency, Patient shall call 911 or proceed to the nearest emergency facility and follow the directions of emergency personnel;
(e) Patient will not use Electronic Communication for communications regarding sensitive personal information. In such cases Patient will call the designated phone number to communicate with Practitioner or her designee(s);
(f) If Patient does not receive a response to Patient’s Electronic Communication message within the time frame specified in the Agreement (typically one business day, unless Patient indicates in the Electronic Communication that longer or shorter time-frame is desired), Patient will use another means of communication to contact Practitioner or appropriate representative; and
(g) Neither Practitioner nor any of Practice’s agents, consultants or representatives will be liable to Patient for any loss, damage, cost, injury or expense caused by, or resulting from: (1) a delay in response to Patient due to technical failures, including but not limited to, technical failures attributable to internet service provider, power outages, failure of electronic messaging software, failure by Practitioner, or any of Practice’s agents, consultants or representatives to properly address Electronic Communication messages, failure of computers or computer network, or faulty telephone or cable data transmission; (2) any interception of Electronic Communication by a third party; or (3) Patient’s failure to comply with the guidelines regarding use of Electronic Communication set forth in this Section.
6. Term and Termination.
Unless earlier terminated as set forth below, the initial term of the Agreement shall be for one year, commencing on the Effective Date and terminating on the day following the first anniversary of the Effective Date (the “Initial Year”). Thereafter, this Agreement will automatically renew on the first-anniversary date and all subsequent anniversary dates thereof unless you provide sixty (60) days' written notice prior to the anniversary date. The Agreement may be terminated as follows. In no case, will the Membership Fees be refundable.:
(a) Practice may terminate this Agreement, at any time upon:
(i) Patient’s breach of the Agreement if such breach is not cured within 10 days; or
(ii) Patient fails to pay the periodic fee; or
(iii) Patient has performed an act of fraud; or 3
(iv) Patient repeatedly fails to adhere to the recommended treatment plan; or
(v) Patient is abusive and presents an emotional or physical danger to the staff or other patients of the Practice; or 30 days prior written notice to Patient, without cause;
(b) This Agreement automatically terminates upon the death or dissolution of the other Party.
7. Independent Medical Judgment. Notwithstanding anything to the contrary contained in this Agreement, Practitioner retains full and free discretion to, and the Practitioner shall exercise her best professional medical judgment on behalf of Patient with respect to medical services rendered to Patient. Nothing in this Agreement shall be deemed or construed to influence, limit or affect a Practitioner’s independent medical judgment with respect to provision of medical services to Patient by Practitioner or Practice.
8. Terms of Usage. Practice may designate, from time to time, certain Terms of Usage for Patients as supplement to this Agreement by providing written notice to patients of such terms. In the event Practice designates any Terms of Usage, such terms shall control over conflicting terms in this Agreement.
9. Change of Law. If there is a change in any state or federal law, regulation, rule or interpretation thereof which affects this Agreement or the activities of either party under this Agreement, and either party reasonably believes in good faith that the change will have a substantial adverse effect on that party’s rights or obligations under this Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms of this Agreement. If the parties are unable to reach an agreement concerning the modification of this Agreement within thirty (30) days after the date of the notice seeking renegotiation, then either party may terminate this Agreement by written notice to the other party; in such case Patient will be entitled to a refund of prorated portion of the Membership Fee paid by the Patient for the year in which termination becomes effective.
10.Severability and Assignment. If any provision of the Agreement is declared invalid or illegal for any reason whatsoever, then notwithstanding such invalidity or illegality, the remaining terms and provisions of the Agreement will remain in full force and effect in the same manner as if the invalid or illegal provision had not been contained herein. Patient may not assign the Agreement to another individual.
11. Notice. Any communication required or permitted to be sent under this Agreement (other than communications referenced in Section 5 relating to Patient’s PHI) will be in writing and sent via facsimile, recognized overnight courier, or certified mail, return receipt requested, to the addresses set forth below. Any change in address will be communicated to the Parties in accordance with the provisions of this Section 11.
12.Legal Significance. Patient acknowledges that this Agreement is a legal document and creates certain rights and responsibilities. Patient also acknowledges having had a reasonable time to seek legal advice regarding the Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of this Agreement.
13.Governing Law; Arbitration. This Agreement shall be governed and interpreted in accordance with, and the rights of the parties shall be determined by, the laws of the State of New Hampshire, without regard to conflicts of laws principles. The parties intentionally and voluntarily waive any right to a trial by jury in any matter arising out of this Agreement. Any dispute between Patient and Practitioner and/or Practice or their respective affiliates and agents arising under or relating to this Agreement shall be resolved exclusively by binding arbitration in New Hampshire, before a neutral arbitrator, under the auspices of the American Arbitration Association, in accordance with the Expedited Rules and Procedures for Commercial Arbitration in effect at the time of arbitration. Any award rendered pursuant to such arbitration shall be final and binding upon the parties, and judgment upon the award rendered by the arbitrator may be entered in any court having jurisdiction over parties. Each party shall bear its own costs and attorneys’ fees in connection with any such arbitration.
14.Waiver. The failure of a party to insist upon strict adherence to or performance of any term of the Agreement on any occasion will not be considered a waiver of the right to require adherence on any other occasion or regarding any other matter.
15.Miscellaneous. This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted. Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text.
6.Entire Agreement. The Agreement contains the entire agreement of the parties and supersedes all prior agreements and understandings between the Parties regarding the subject matter hereof. The Agreement may only be amended by a written agreement signed by the Parties. Notwithstanding the foregoing, the Practice may amend this Agreement to the extent required by federal, state or local law, rule or regulation by sending Patient thirty (30) days advanced written notice of any such change. Any such changes are incorporated by reference into this Agreement without the need for signature by the parties and are effective as of the date established by the Practice except that the Patient shall initial any such change at the Practice’s request.
If you have a complaint, please contact Lifestyles by Noor LLC clinic directly or Lifestyles by Noor LLC in any of the following ways:
Email: info@lifestylesbynoor.com
Mail: 9 Hampton Road, Exeter, NH 03833
Phone: (603) 686-5515
Fax: (603) 583-5610