Photo two boxes.
Dr. Janene Martin
2345 York Road, Suite 102
Lutherville-Timonium, MD 21093
410.296.4005 410.296.4636 fax
www.sunlightnaturalhealth.com
Wellness Plan Contract
This contract is between Sunlight Natural Health, hereafter referred to as “Sunlight Natural Health”
(Janene Martin, N. D. d/b/a Sunlight Natural Health) and ______, hereafter
referred to as “Patient”. This contract establishes an agreement for Sunlight Natural Health to provide
Naturopathic assessment and consultation services to the Patient. The terms of this agreement are
detailed below:
COVERED NATUROPATHIC SERVICES:
Sunlight Natural Health agrees to provide “Covered Naturopathic Services” to the Patient.
Covered Naturopathic Services are designed to provide supportive, Naturopathic care to promote
wellness of the Patient through natural means and remedies to further health and wellness, including
assessment and patient education and counseling about nutritional interventions; herbal and
homeopathic remedies; lifestyle modifications and a range of other natural interventions/consultations. Covered Naturopathic Services include the following:
a. A total of eleven (11) visits per year for New Patients, total of six (6) visits for current patients or a
Family plan of either twenty (20), thirty (30), forty (40), fifty (50), sixty (60) hours/year which may
be shared among your immediate family members.
b. NEW PATIENT VISIT (2 hours) consists of current and past medical history review and, non-invasive
pertinent physical exam. Blood work-up and additional warranted testing is recommended as
necessary.
c. REVIEW OF FINDINGS (2 hours): Based on a careful consideration of your past and current work-up
and clinical history taken during your new patient visit you will receive detailed written
recommendations in the areas of lifestyle, diet, supplements, homeopathic prescriptions and your
individualized Blood Nutrition Report.
d. GENERAL FOLLOW-UP VISITS (50 minutes): Longer appointments may be scheduled as necessary if
planned accordingly but will be deducted from total annual visits allotted.
e. Access to physician through email for quick updates, clarification of previously given recommendations is available through the established “patient only” email address.
f. Appropriate referrals when indicated.
The Covered Services are part of Sunlight Natural Health’s Wellness Plan. Under the Wellness Plan, the
Covered Medical Services are provided to the Patient on an annual fixed fee basis. Under the Plan, the
following terms apply:
a. No denial for coverage under the Plan for pre-existing conditions;
b No insurance co-payments apply to the Costs for Services;
c. No pre-authorization is required;
d. No referrals are necessary;
e. The Plan has open enrollment at any time during the year;
f. Referrals to specialists will be made as appropriate and as indicated;
g. Services will be provided during regular business hours of Sunlight Natural Health.
SERVICES EXCLUDED:
Charges for any test(s), supplements, or services not listed in Exhibit A including scheduled phone
consults are the responsibility of the Patient. Professional services that are not covered by this contract
may be provided to the Patient by Sunlight Natural Health through appropriate separate financial
arrangements.
This contract does not cover or include urgent services, emergency services requiring hospitalization, or services of other physicians or health care providers.
COSTS FOR SERVICES:
The cost for services provided under this contract is a minimal annual fee of $900.00 plus “time of
service” fees. The “New Patient” and “Review of Findings” time of service fees are $215 each. New
Patient Wellness Package general follow-up appointment cost is $107.50. The Current Patient Wellness
Package general one (1) hour follow-up cost is $27.00. The annual fee may be paid in full, in advance, or
in monthly installments. Monthly fees shall be paid by direct draft on the 1st day of each month. If
entering into this agreement any day other than the first of the month your first monthly draft will occur on the date of this agreement. The remaining 11 drafts will be deducted from your designated account on the next following first day of the month for the next 11 months. Visits extending beyond the scheduled appointment time will be charged a pro-rated fee based on $177/hour. Any additional visits over the
allotted number of visits per year will be charged at $177/hour.
All fees must be paid as due in order for the Patient to continue to receive the Covered Services under this contract with Sunlight Natural Health.
Sunlight Natural Health reserves the right to change the annual fee or the monthly installment for service upon renewal.
If any monthly service charge is declined for payment there will be a fee of $25 assessed per
monthly decline. The Patient will be given (5) business days to pay the balance due, including the
monthly service charge and the decline fee totaling $100. Failure to pay the balance due will result in
suspension of the contract and/or the ability to schedule further appointments.
AGREEMENT TERM
This contract shall be in effect for 12 calendar months from the date of its execution. Full payment of the annual fee for services or monthly fee during the term of this contract guarantees this contract for one (1) year from the date of the execution of the contract. Failure to pay the annual or monthly fee will
terminate this contract without notice or demand. All allotted visits must be used within the agreed
contract calendar year and may not be extended for use beyond the agreed contract calendar year.
This contract is renewable annually with the mutual consent of Sunlight Natural Health and the Patient.
EARLY TERMINATION
The Patient may cancel this contract at any time during the year by giving thirty (30) days written notice to Sunlight Natural Health. In the event of cancellation, the Patient’s completed appointments will be
re-billed at the non-wellness package rate of $200 per hour. Any difference in balance owed to Sunlight Natural Health will be due upon early termination date. Once the patient has paid the difference for
rebilled visits this contract will terminate and all further monthly commitments and financial obligations of the Patient to Sunlight Natural Health will end.
No refunds will be paid by Sunlight Natural Health to the patient upon early termination of this
agreement.
The Patient will then be welcome to continue to receive services from Dr. Martin at the non-wellness plan rate and all charges will be due at the time of each office visit.
VISIT CANCELLATION / RESCHEDULING POLICY:
For any visits canceled with less than two open business days notice, the patient will be charged
a full visit fee, except in the case of documented family or personal medical emergency.
Signing below signifies that the Patient has read this contract and agrees to the terms specified within.
Patient Name:______Check One:
£ New Patient (13 hours per year)
Signature: ______£ Current Patient (6 hours per year)
£ Family Pkg.: ( ______hours per year)
Date:______
Sunlight Natural Health by Janene Martin, N. D. Contact Information:
Sunlight Natural Health
Date:______Website: www.sunlightnaturalhealth.com 2345 York Road, Suite 102
Baltimore, MD 21093
Phone: (410) 296-4005
Fax: (410) 296-4636
Email:
December 10, 2016