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

Services
Primary Care Plan (PCP) is a system to provide discounted fee for service, office-based primary medical care. In exchange for a monthly membership fee, members will receive office visits according to the fee schedule set forth in Step 2: Application. PCP covers only office visits at Family Doctors of EastProvidence, 1445 Wampanoag Trail., East Providence, RI. PCP covers no services other than those specifically stated in this document. PCP is not health insurance.

Regular Office Hours (Monday-Friday, 9am to 5 pm, excluding holidays).
PCP members will receive all necessary office visits, during regular business hours (Monday through
Friday 9am to 5 pm, excluding weekends and holidays), at Family Doctors of East Providence for a fee of
$5.00 per visit, due at the time of service. All necessary office visits includes:
• 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.
If, after discussing the problem with you, a physician from Family Doctors of East Providence or a
covering physician from Family Medicine Specialists or Spectrum Family Health agrees to see you, then a
fee of $25.00 is due at the time you are seen.
If our covering physician cannot see you, he or she will still provide recommendations by telephone. If
those recommendations include going to an urgent care facility then you will be responsible for any charges
incurred. However we will credit an amount equal to one-month membership to your PCP account if the
following conditions are met:
1. We receive documentation from the covering physician that he or she recommended you go to the
urgent care facility.
2. You provide us the receipt of payment to the urgent care facility.
Please note that the above conditions are intended to provide a cushion against non-emergency charges
incurred after hours and are not for the purpose of paying for emergency care. Thus you are eligible for the
credit only if the above conditions are met, which does not include credit for charges or payments to any
facility or provider other than an urgent care facility (specifically, but not limited to, hospital emergency
rooms).

Additional Charges
The following list contains items that may incur additional charges, even during an office visit at Family
Doctors of Eats Providence:
• Medical supplies beyond routine immunizations (examples: 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.
• Billing and/or escrow adjustment fees resulting from unpaid balances.

Application Fee
There is a non refundable application fee of $15 per individual.
Reapplication Fee
Should any individual’s membership be interrupted for any reason, they may reapply upon payment of a
$50 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.
Minimum Membership Term and Early Termination Fee
There is a minimum 6 month continuous membership required. Any individual terminating their
membership or in default of monthly membership payments prior to 6 months agrees to pay a $100 early
termination fee.

Payment Terms
• Fees are according to the schedule set forth in Sep 2: Registration.
• Office visit fees (including after hours, weekend and holiday visits) are payable at the time of service.
• For patients who are invoiced monthly:
   o Invoices will be mailed during the first week of each month. Payments are due prior to the end
of the month in which the invoice is received. Fees shall be applied to membership in PCP for
the immediate prior month (example: fee due by April 30 is applied to March membership).
• For patients who choose credit card auto debit:
   o Credit cards will be debited on the first business day following the first of each month. Fees
shall be applied to membership in PCP for the immediate prior month (example: credit card
payment debit on April 1 is applied to March membership).
• If payment is not received on the due date, a seven-business day grace period will be allowed.
• If payment is not received within the grace period, we reserve the right to:
   o Terminate your PCP membership.
   o You may still be seen on a regular fee for service basis at Family Doctors of East Providence.
   o You may reapply to PCP upon payment of a $50.00 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 will automatically be renewed every month unless terminated by either party as set forth
below.

Termination
Either party, without cause, may terminate this agreement upon 30 days written notification.

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.