Capital Healthy Living Participant Agreement

SERVICES AGREEMENT

            This SERVICES AGREEMENT (“the Agreement”) is effective on the date the last Party signs this Agreement (“Effective Date”), between Population Health Management Services, LLC d/b/a Capital Healthy Living (“PHMS”) and "Enter Name on Form Below" (“Participant” or “You”) (hereinafter referred to individually as a “Party” and collectively as the “Parties”).

1. SERVICES.  PHMS will provide the services set out in Exhibit “A” to You (the “Services”) which may be changed from time to time after PHMS gives You notice. In the event that something beyond PHMS’s control (like severe weather, etc.) prevents PHMS from performing the Services, the Parties will work together to reschedule the Services.
2. TERM & TERMINATION.  You will receive services at a mutually agreed upon date after You and PHMS sign the Agreement.  The Agreement will automatically renew monthly for one-month periods until either Party terminates this Agreement.  Either Party may terminate this Agreement for any reason at any time. PHMS may immediately terminate this Agreement in the event that (i) You breach this Agreement, (ii) You violate any applicable law; or (iii) if PHMS believes, in its sole discretion, that its personnel’s safety or wellbeing is in jeopardy.
3. PAYMENT.  You shall pay PHMS a monthly fee of $50.00, due on the first day of every month in which you receive the Services.  The monthly fee shall not be prorated in the event of termination.
4. USE OF VENDORS.  In connection with the Services, PHMS will provide You with connections to certain vendors for short-term tasks and transportation (“Vendor” or “Vendors”).  The Vendors are not employed by PHMS.  PHMS does not supervise, control, or monitor the Vendors’ work.  PHMS is not responsible for the acts or failure to act of Vendors and their employees.  The Program only enables connections between You and Vendors as a convenience to You.  YOU AGREE TO RELEASE PHMS AND ITS EMPLOYEES FROM LIABILITY IN CONNECTION WITH THE ACTS OR FAILURE TO ACT OF THE VENDORS.
5. RULES FOR PARTICIPANT.  PHMS has zero tolerance for any verbal or physical aggression by You or Your family, friends, or agents towards PHMS, its agents, personnel, or any Vendor. You hereby represent and warrant that You will provide a reasonably safe environment at Your home while PHMS personnel are providing Services under this Agreement. PHMS reserves the right to immediately terminate this Agreement for violation of this Section and pursue any remedies available to it at law or in equity.
6. DISCLAIMER OF WARRANTIES.  PHMS makes no representations or warranties regarding the Services it provides or those of any Vendor.
7. INDEMNIFICATION AND INSURANCE.  If PHMS gets sued because you breached the Agreement, acted negligently, or violated a law, you will have to pay for all costs PHMS incurs as a consequence, including reasonable attorney fees.  You will maintain adequate insurance on any property in which PHMS personnel will provide the Services.
8. ASSURANCE OF CONSUMER AND PROVIDER CHOICE. The Parties acknowledge and agree that all health and health-related professionals employed by or under contract with PHMS, retain sole and complete discretion to refer patients to any provider that best meets Your clinical needs. The Parties acknowledge that all consumers have the freedom to choose (and/or request) any provider of services. 
9. CONFIDENTIALITY. PHMS acknowledges that, in the course of the performance of Services, it may learn certain confidential information You, including protected health information (“Confidential Information”). You expressly acknowledge and consent to PHMS and its personnel’s access to such Confidential Information.  PHMS agrees to maintain the privacy and confidentiality of all information, including Confidential Information, regarding your personal information in accordance with all applicable federal and state laws and regulations (including, but not limited to, the Health Insurance Portability and Accountability Act and its implementing regulations set forth at 45 C.F.R. Part 160 and Part 164 (“HIPAA”), 45 C.F.R. Part 2.    
10. GOVERNING LAW.  This Agreement shall be interpreted, construed, and governed according to the laws of the State in which the Services are provide.
11. GENERAL PROVISIONS.  If any term or provision of this Agreement or the application thereof to any person or circumstance shall to any extent be invalid or unenforceable, the remainder of this Agreement shall remain valid and enforceable.  This Agreement is for Your benefit only. This Agreement represents the Parties’ complete understanding regarding the Services.  No oral agreements will be acceptable to supplement or change the Agreement.  All notices shall be in writing only.  Any failure by PHMS to enforce a term of this Agreement shall not prevent further enforcement of that term.

Population Health Management Services, LLC    Participant

Exhibit “A”

            PHMS agrees to provide Participant the following Services under this Agreement:

1. A Life Care Manager (“LCM”) will be assigned to Participant to conduct an initial assessment based on Participant’s goals and needs and a care plan will be created for Participant (“Care Plan”).
2. The LCM will coordinate engagement, care management services, coaching, and emotional and cognitive support to Participant on an as-needed basis and serve as the point person for other services provided by this program. These services will be provided during normal working hours (e.g., 9 a.m. to 5 p.m.) Monday through Friday. On call service will be available for extended hours for urgent services.
3. A Life Care Coordinator (“LCC”) will be assigned to Participant to assist with scheduling for Capital Health Medical Group physicians, Capital Health – Hopewell’s Wellness Center access, social activities, transportation, and non-medical service referrals.
4. Upon request, the Participant shall receive transportation from home to all Capital Health facility and Capital Health Medical Group physician appointments and once-weekly transportation to a Capital Health hosted social event or wellness class of Participant’s choosing.
5. Participant shall receive transportation for up to two (2) non-medical appointments per month within fifteen (15) miles of Participant’s home. Unused non-medical transportation services may not be carried over to future months. 
6. Participant shall receive access to one (1) Capital Health social event of wellness/exercise class per week.
7.  Participant shall receive, upon request, one (1) customized exercise regimen training session per year at Capital Health – Hopewell’s Wellness Center.
8. Participant will receive linkage to Capital Health and community social and wellness events.

By clicking “accept” you:  (i) acknowledge that you have read the terms of the Agreement; (ii) consent to the terms of this Agreement; and (iii) intend to authenticate this contract with the same force and effect as manual signatures.