I hereby authorize Richard M. Levin, M.D., PSC, Richard M. Levin, M.D., individually, and their assistants, associates and designees (“Dr. Levin”) to perform a microsurgical tubal anastomosis (the “Procedure”) on me. I understand that a Tubal Reconstructive Surgery Informed Consent, will be executed by me before the Procedure. This Business Terms Agreement for Surgery (hereinafter, “Agreement”) governs the financial and business terms that will apply to my obtaining Dr. Levin’s services.
I understand that the physicians and/or their designees in attendance at such operation or Procedure(s) for the purpose of administering anesthesia, and the physicians and/or their designees performing services involving pathology and radiology, are not the agents, servants or employees of the hospital nor of Dr. Levin, but are independent contractors and that the individuals administering anesthesia shall consult with me about the administration of anesthesia and will obtain a separate consent for the administration of anesthesia.
I acknowledge that I may receive one year of follow-up infertility consultations and office-based testing to facilitate my ability to conceive. Such infertility aftercare is given as a courtesy by Richard M. Levin, M.D., PSC. and is not given as part of my payment at all, nor does it confer any monetary value for me. The date of such care shall commence 58 weeks from the day of the reversal Procedure should i request such care. I understand that any type of hospital-based testing or non-office testing will not be included. I further acknowledge and understand that any ongoing care will be done only if Dr. Levin believes that it is medically indicated. I understand that any ongoing care will only be provided to patients who display appropriate behavior/demeanor towards any and all staff at Jewish Hospital and at the office of Richard M. Levin, MD., PSC. I also acknowledge that should I seek any type of gynecologic or infertility care following my Procedure without first consulting with Dr. Levin and receiving his approval of such care, that I might forfeit my right to follow-up care of any type.
I acknowledge that the moneys I have paid to Richard M. Levin, M.D., PSC. cover the Procedure only and should I need further care or services beyond the Procedure that I will be fully responsible for those charges. Such care may include care for non-Procedure medical needs, hospitalization after the Procedure, Emergency Room care both immediate and subsequent and other possible non-Procedure care.
I understand and agree that the Procedure is being offered on a prepaid basis only. This Procedure, which includes payments for multiple vendors and multiple services, will not be unbundled for payment by me, my health insurance company or for other purposes. I understand and agree that this multi-vendor, multi-service package pricing will exclude the various vendors from any and all contractual obligations they currently have with any and all insurance companies, groups or other organizations in relationship to the Procedure. I understand and agree that I am responsible for any and all payments to Dr. Levin, that his services are not covered under my health insurance policy and I will not submit any of the bills for the services herein to my insurer.
Appointment Cancellation: I understand and agree that unless canceled at least 24 hours in advance, that any missed office or consultation appointment will be charged to me at the rate of a normal office visit.
Procedure Cancellation or Missed Procedure Policy: Any notification of cancellation must be delivered in writing (by Certified U.S. Mail or overnight delivery service) to Dr. Levin’s office (a fax is not sufficient). Upon scheduling surgery, Dr. Levin incurs substantial cost in planning and booking the necessary facilities and supporting personnel to perform the surgery. Therefore, I understand and agree that:
(A) A “Standard Reversal” patient is defined as a woman who pays the full amount of her Procedure cost at or before the Procedure is actually scheduled. A “Standard Reversal” patient understands and agrees that: i) f I miss a scheduled surgical Procedure or cancel the Procedure less than two (2) weeks in advance, I will be charged the entire fee for the scheduled Procedure, which amount is a reasonable estimate of the damages and out-of-pocket expenses to Dr. Levin associated with such cancellation. ii) If I cancel a scheduled surgical Procedure more than two (2) weeks in advance but less than six (6) weeks in advance, I will be charged a cancellation fee equal to 50% of the amount paid for the Procedure, which amount is a reasonable estimate of the damages and out-of-pocket expenses to Dr. Levin associated with such cancellation. iii) If I cancel a scheduled surgical Procedure more than (6) weeks in advance, I will be charged a cancellation fee equal to 25% of the amount paid for the Procedure, which amount is a reasonable estimate of the damages and out-of-pocket expenses to Dr. Levin associated with such cancellation.
(B) A “Fast-track” patient is defined as a woman who agrees to the Online Fast-Track agreement at http://www.babies-by-levin.com/consent_reversal.htm and/or a woman who prepays less than complete payment of the reversal Procedure and arranges for the scheduling of said Procedure. Such patient understands that: If I miss or cancel a scheduled surgical Procedure, regardless of the cause of said cancellation/missed Procedure, then I will be charged the entire fee for the scheduled Procedure, which amount is a reasonable estimate of the damages and out-of-pocket expenses of Dr. Levin associated with such cancellation. I also understand and agree that I will forfeit the amount I have prepaid at the time of scheduling this Procedure and that paragraphs A & C of this main paragraph #7 do not apply to me as a Fast-Track patient.
(C) A “Prepay24” patient is defined as a woman who has signed an agreement labeled “Installment agreement for patients ...” received from Dr. Levin. A “Prepay24” patient understands that: If I (the patient) cancel the agreement at anytime or miss the reversal Procedure, regardless of the cause of said cancellation or missed reversal Procedure, then I will be charged the entire fee for the reversal Procedure, which amount is a reasonable estimate of the damages and out-of-pocket expenses of Dr. Levin associated with such cancellation or missed reversal Procedure. I also understand and agree that I will forfeit the complete amount of money I have prepaid prior to the time of cancellation or prior to the time of the missed reversal Procedure. I understand that paragraphs A-B of this main paragraph #7 do not apply to me as a “Prepay24” patient.
Procedure Cancellation for Health Reasons: In order to safe-guard the health of the patient and attending medical staff, patients must present for surgery in good physical condition and in adequate health for elective surgery (as determined by the attending medical staff). If a patient does not comply with the following rules, her surgery will be cancelled. The surgery may not be rescheduled and no refund will be available regardless of whether the Procedure is rescheduled or not. Therefore the patient must:
A) Be in compliance with all preoperative instructions given to her within Dr. Levin's pre-operative orders (including arriving at “Registration” on the correct date and at the correct time).
B) Be free of all listed medications within Dr. Levin's preoperative orders
C) Be accurate and consistent with latex allergy reporting on the medical history. If patient reports the day of surgery with a positive latex allergy that was not reported on the medical history and no notification was given to the treating physician prior to the day of surgery so that the appropriate modifications could be made to the operating room supplies and other protocols then the case will be cancelled and may not be rescheduled. In such event no refund will be available regardless of whether the Procedure is rescheduled or not.
D) Be current on all of her currently prescribed medications
E) Be free of concurrent disease which is either untreated or inadequately treated and is known or should have been known to the patient
F) Be free of infectious diseases which might cause a health problem for her or the treating medical staff
G) Be free of skin infections which might cause a health problem for her or the treating medical staff
H) Be free of MRSA and other antibiotic resistant organisms. Failure to let Dr. Levin know of such infections in a timely fashion so that another patient can be substituted into that surgical slot will constitute failure to meet these rules and her surgery will be cancelled, not rescheduled and no fee refund made to her.
Weight Restrictions: I must have permission in writing from Dr. Levin to schedule the Procedure and then have the Procedure if I am above the 50% height/weight guidelines as set out on Dr. Levin's web site at http://www.babies-by-levin.com/mobile/weight_mbl.html. If I present to Dr. Levin for the Procedure and do not meet these height/weight guidelines or I am above the 50% limit, then Dr. Levin may deny my Procedure or if the Procedure is not denied I will be charged the currently posted surcharge posted at the office of Dr. Levin. In the event Dr. Levin denies my Procedure because I do not meet those height/weight guidelines or I am above the 50% limit, or if I choose not to pay the appropriate surcharge then I understand and agree that my Procedure will be cancelled and I will be charged the entire fee for the scheduled Procedure, which amount is a reasonable estimate of the damages and out-of-pocket expenses to Dr. Levin associated with such cancellation.
I understand and agree that Dr. Levin is not providing my Obstetric or Gynecologic care and that I have my own Obstetrician/Gynecologist. I further affirm that I am up to date with my gynecologic care, including my Pap smears and any and all recommended care that my local doctor has suggested.
I understand and agree that in the event Dr. Levin is unable to perform my surgery on the scheduled date for any reason that I am willing to be placed on his operating schedule at a future date and time that is mutually agreeable and that I do not expect any compensation for such a missed or cancelled Procedure nor do I expect to be compensated for travel expenses, lost work or any other type of expense.
I understand and agree that Dr. Levin is free to post any and all e-mails, cards, letters, etc which are of a testimonial nature on his web site for other patients to read without any further authorization on my part.
I understand and agree that credit card refunds will not be made until the credit card charge posts on the monthly statement of Richard M. Levin, MD., PSC. Once it has posted to this account, the amount of the refund, less the administrative charge added at the time of the initial transaction, will be mailed to you in the form of a check on the account of Richard M. Levin, MD., PSC. No refunds will be put back on your credit card.
I understand that in the event that I am in breach of this contract and fail to pay any portion of the professional fee owed to Richard M. Levin, MD., PSC for my medical evaluation and/or treatment, and such breach or failure to pay necessitates the services of a collection agency and/or law firm to collect such fees, I hereby agree to pay any and all costs associated with collecting the balance due, including court costs, reasonable attorney fees and other associated costs incurred by Richard M. Levin, MD., PSC.
I understand and agree that the complete payment for the Procedure is due before (or at the time of) scheduling of the Procedure with the office of Richard M. Levin, MD., PSC. I agree that any amount I owe for out-of-office follow-up services that is not paid in full within sixty days (60) of the service date will be subject to a late charge of 15% of the unpaid balance or $25.00, whichever is less. All unpaid amounts shall bear interest from and after the 60th day after the service date at a rate equal to the lesser of 15% per annum or the maximum amount Dr. Levin may collect without violating the usury laws of the applicable jurisdiction.
I understand and agree that Richard M. Levin, MD., PSC. and Richard M. Levin, MD are only willing to perform the Procedure on me under the terms that I will not speak either publicly or privately about any and all people, organizations, corporations, situations, or any other matters related to the Procedure in such a fashion that a normal group of American citizens would interpret as negative, hostile, maligning, defamatory or in any other way intended to shape opinion against Richard M. Levin, MD., PSC. or Richard M. Levin, MD. nor will I allow my name or person to be associated in such fashion. Should I violate any portion of this clause then I agree to pay to Richard M. Levin, MD., PSC. and Richard M. Levin, MD, each separately, the amount of $250,000.00 as reasonable damages to each of them and that any balance which remains unpaid I will pay 10% interest on the unpaid balance compounded monthly until the full amount is paid.
I understand and agree that neither the rights nor the duties created by this Agreement shall be assignable or transferable unless such assignment or transfer is agreed to, in writing, by all parties hereto.
I agree that this Agreement shall be governed by the laws of the Commonwealth of Kentucky. The parties agree that any legal action commenced under or concerning this Agreement, or between the parties whatsoever, whether for breach of this Agreement or otherwise, shall be brought in Jefferson County, Kentucky. I further understand and agree to indemnify Richard M. Levin, MD, PSC and Richard M. Levin, MD for any and all costs or judgments, legal and otherwise, incurred by it/him in the event of any civil litigation brought on my behalf or against me, including but not limited to reasonable attorney fees.
I consent that in the event that any of the provisions of this Agreement are deemed to be invalid or unenforceable, the same shall be deemed severable from the remainder of this Agreement and shall not cause the invalidity or un enforceability of the remainder of this Agreement. If such provision(s) shall be deemed invalid due to scope or breadth, then said provision(s) shall be deemed valid to the extent of the scope or breadth permitted by law.
All blank spaces in this document have been either completed or crossed off before my signing. My signature below constitutes my acknowledgement (1) that I have read or have had read to me and agreed to the foregoing; (2) that the proposed operation or Procedure, along with the potential risks, has been satisfactorily explained to me by my physician and that I have all of the information that I desire; and (3) that I consent to the above-described Procedure(s).
Paragraph added on 5/31/2016 for clarification of existing office policy. Any case requiring rescheduling for any reason requires a $500.00 fee paid prior to case being rescheduled. Additionally any remaining balance due for the full payment of the surgery must also be paid before the case will be rescheduled.
Use of this website and the services of Richard M. Levin, M.D., PSC and/or www.babies-by-levin.com denotes your acceptance of these Terms of Service. Document Effective Stating 2/14/2007.