Family Doctors of East Providence, Inc.
Primary Care Plan Contract
(Submit the form that follows below to indicate that you have read and agree to the contract)

Click here for a printable PDF version

General
Primary Care Plan (PCP) is a discounted office-based primary medical care payment fee schedule. In exchange for your initial application fee and an annual enrollment fee, you will receive office visits according to the fee schedule outlined below.

PCP covers office visits at Family Doctors of East Providence, 1445 Wampanoag Trail, East Providence, RI. PCP covers no services other than those specifically stated in this document.

Your Application Fee and your Annual Enrollment Fee are administrative fees only. They are not pre-payment for any services. They are not health insurance. Payment for all services comes only from the per office visit fee table described below.

Services
As a PCP patient, you will receive all necessary office visits, during regular business hours at Family Doctors of East Providence (Monday-Friday, 9am to 5 pm, excluding holidays).

All necessary office visits include:
 • One annual well exam for patients age 18 years of age and above.
 • One annual pediatric well exam for patients 3 through 18 years of age.
 • Two pediatric well exams for patients two to three years of age.
 • Three pediatric well exams for patients 12 through 23 months of age.
 • Six pediatric well exams for patients birth through 11 months of age.
 • For all patients, all medically necessary acute/sick visits.
 • For all patients, all medically necessary follow-up visits.

After Hours, Weekends and Holidays
Since PCP provides coverage only during regular office hours (Monday through Friday 9am to 5 pm, excluding weekends and holidays), we cannot guarantee that you can be seen by one of our physicians outside of regular hours. If you have an urgent medical problem outside regular office hours, but not a medical emergency (dial 911 for emergencies), call our phone at (401) 434-0770 and follow the instructions to reach the physician on call.

Fees
 • APPLICATION FEE: There is a non refundable one- time Application Fee of $15 per individual.
 • ANNUAL ENROLLMENT FEE: You choose your Annual Enrollment Fee of either $299, $149 or $99, depending on your desired fee for each office visit.
     If you choose an annual enrollment fee of:         Your fee for each office visit will be:
            $299                                                                                  $0
            $149                                                                                  $25
            $99                                                                                     $40

• REAPPLICATION FEE: Should any individual’s membership be interrupted for any reason, they may reapply upon payment of a $30 reapplication fee. Acceptance back into PCP shall be at the sole discretion of Family Doctors of East Providence. If your application is declined, your application fee will be refunded.
• ADDITIONAL CHARGES: The following list contains items that may incur additional charges, even during an office visit at Family Doctors of East Providence:
      • Medical supplies (examples: immunizations, in-office lab tests, medications administered in the office, orthopedic          devices given from the office).
      • Copying of medical records.
      • Appointments missed without 24 hours notice.
      • Added fees resulting from unpaid balances.

Payment Terms
Your Annual Enrollment Fee is due upon acceptance into the PCP program and on the first business day of each annual enrollment, if you wish to maintain continuous membership and avoid the reapplication fee (see below). If payment is not received on the due date, a seven-business day grace period will begin. If payment is not received within the grace period, we reserve the right to:
 •Terminate your PCP membership.
 •You may still be seen on a regular fee for service basis at Family Doctors of East Providence.
 •You may reapply to PCP upon payment of a $30.00 reapplication fee.   Acceptance back into PCP shall be at the sole   discretion of Family Doctors of East Providence.  If your application is declined, your application fee will be refunded.

Renewal
This agreement must be renewed annually. We will contact you by letter or email approximately 30 days before your enrollment anniversary.

Termination
Either party, without cause, may terminate this agreement upon 30 days written notice. Application Fees and Annual Enrollment Fees are non-refundable, in whole or in part.

Authorization
I give permission for Health Access Rhode Island to send electronic newsletters to me. I understand no
confidential information other than my email address be shared with Health Access Rhode Island.