Step 1. Contract      
Read the Agreement and then complete and submit the form that follows. When you are finished you will be taken to Step 2.

Click here for a printable PDF version

General
Primary Care Plan (PCP) is a self-pay fee schedule at Family Doctors of East Providence.  Once a year, you purchase a "Discount Buy-Down", which then entitles you to office visit fees that are deeply discounted off our regular fees.  There are three levels of discount that you can purchase.  For $299 per year you can buy $0 office visits.  For $149 per year, you can buy $25 office visits.  For $99 per year you can buy $40 office visits. 

You agree that payment of your Discount Buy-Down fee is not health insurance.  It is not prepayment for or retainer against future payment for any services.  All health services are paid for at the time of the visit soley by your discounted office visit fee.  Your Discount Buy-Down only purchases your office visit discount level.

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.

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.  This is an administrative fee that does not imply prepayment or retainer against future payment for any services.
 • ANNUAL DISCOUNT BUY-DOWN FEE: You choose your Discount Buy-Down fee of either $299, $149 or $99, depending on your desired fee for each office visit.
     If you choose the Discount Buy-Down 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 Discount Buy-Down 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 21 days before your enrollment anniversary.

Termination
Either party, without cause, may terminate this agreement upon 30 days written notice. Application Fees and Discount Buy-Down 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.