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Join Canopy Pediatrics or Access Direct Primary Care

Part of the Innovative Care Group

Our goal is that both Canopy Pediatrics and Access Direct Primary Care will be the best, most patient-centered medical practices in the country. If this is not your experience, please inform Dr. Homan or Carmen Colón, NP/FNP!

How to Complete the Registration: Please send us a text or give us a call if you need help (contact either one of us).

Carmen Colón, NP/FNP Access Direct Primary Care: 850-820-6129
Dr. Russell Homan, Canopy Pediatrics: 850-331-7929

Portal Registration (below): Please register each patient in our patient portal below. Each patient will have their own account with a unique username and password. Through our patient portal, you can make appointments, view medical records, update payment information, and more.
Enter Payment Information: Once registered, please add your payment method. If you are not immediately prompted, please go to the "Invoices and Payment" tab.
Make sure to complete the following sections:
1. My Account Details: Enter your insurance information (if you have insurance)
2. Questionnaires
  1. Authorization to Release Medical Records
  2. Medical History Form
3. My Medications
4. My Pharmacies
Confirm Email Address: Before you can log back into your portal, you must check your email to confirm your email address (common issue).

Thank you for trusting us with your medical care! Text or call us with any issues.

If you are registering as a family, please enter a parent's information as the first patient.

Patient Information

Patient is a minor Patient is an unborn child

Enroll with:

Canopy Pediatrics Access Direct Primary Care

First Name * Middle Name (or initial) Last Name * Date of Birth * Sex * Nickname/Preferred Name

Parent Information

First Name * Middle Name (or initial) Last Name * Date of Birth * Sex * Nickname/Preferred Name Mobile Phone Number * Home Phone Number Work Phone Number Preferred Contact Number Email Address Confirm Email Address I don't have an email address

Contact Information

Mobile Phone Number * Home Phone Number Work Phone Number Preferred Contact Number Email Address Confirm Email Address I don't have an email address

Home Address

Address 1 * Address 2 City * State * ZIP Code *

Emergency Contact

Emergency Contact First Name * Emergency Contact Middle Name Emergency Contact Last Name * Relationship to Patient Emergency Contact Phone Number *

Set Username and Password for Patient Portal

To gain online access to your medical records and secure communications, please create a username and password that you will use to log into the patient portal in the future.

Your username must be at least 4 characters long.
Each participating member on your account must have a unique username and password.

Username *

Your password must be at least 8 characters long and include at least one number or special character.

Password * Confirm Password *

"I consent to having medical information sent to my email address (we cannot guarantee the security of messages delivered by email)." "I consent to having medical information texted to my mobile phone number (we cannot guarantee the security of messages delivered by text.)." "I have read, understand and accept the terms of the Privacy Policy below:" *

The Notice explains how we fulfill our commitment to respect the privacy and confidentiality of your protected health information. This Notice tells you about the ways we may use and share your protected health information, as well as the legal obligations we have regarding your protected health information. The Notice also tells you about your rights under federal and state laws. The Notice applies to all records held by Innovative Care Group's facilities and programs, regardless of whether the record is written, computerized or in any other form. We are required by law to make sure that information that identifies you is kept private and to make this Notice available to you.

Your Rights

When it comes to your health information, you have certain rights.

This section explains your rights and some of our responsibilities to help you.

Get a copy of your paper or electronic medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Correct your paper or electronic medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say "no" to your request, but we'll tell you why in writing within 60 days.
Request confidential communication
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say "yes" to all reasonable requests.
Ask us to limit the information we share
- You can ask us not to use or share certain health information for treatment, payment, or our operations.
  - We are not required to agree to your request, and we may say "no" if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
  - We will say "yes" unless a law requires us to share that information.
Get a list of those with whom we've shared your information
- You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you believe your privacy rights have been violated
- You can complain if you feel we have violated your rights by contacting us using the information in this notice.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to
  
  200 Independence Avenue, S.W.
  Washington, D.C. 20201
  by calling 1-877-696-6775, or visiting HHS.GOV Complaints .
- We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share.

If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us what to share
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In the case of fundraising
- We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you
- We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
- We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
- We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: HHS.GOV consumer home .

Help with public health and safety issues
- We can share health information about you for certain situations such as:
  - Preventing disease
  - Helping with product recalls
  - Reporting adverse reactions to medications
  - Reporting suspected abuse, neglect, or domestic violence
  - Preventing or reducing a serious threat to anyone's health or safety
Do research
- We can use or share your information for health research
Comply with the law
- We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law
Respond to organ and tissue donation requests
- We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
- We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers' compensation, law enforcement, and other government requests
- We can use or share health information about you:
  - For workers' compensation claims
  - For law enforcement purposes or with a law enforcement official
  - With health oversight agencies for activities authorized by law
  - For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
- We can share health information about you in response to a court or administrative order, or in response to a subpoena

Electronic Access

We provide electronic access to your health information via the Cerbo Patient Portal.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: HHS.GOV consumer notice .

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

This notice is effective as of 11/21/2024.

I have read, understand, and accept the terms of the Patient Agreement below:

This is a Patient Agreement entered into today by Dr. Russell Homan, PLLC, DBA Canopy Pediatrics and Access Direct Primary Care (Practice, Us or We), and by the Patient(s) registered above.

Background

The Practice, located at 1963 Village Green Way, Suite B, Tallahassee, Florida, provides ongoing primary care services to its patient/members in a direct pay primary care practice model (DPC). In exchange for certain periodic fees the Practice agrees to provide the Patients specified by You and identified within the Services described and under the terms and conditions contained in this Agreement.

Definitions

Services. "Services" means the collection of services both medical and non-medical, offered to the Patient/Member/s under this Agreement which are identified in Appendix A, which is incorporated by reference and part of this Agreement.
Patient or Member. "Member" or "Patient" means the person or persons for whom we shall provide Services under this Agreement; who are listed in the registration form above; are beneficiaries to this Agreement; and for whom You are the parent or legal guardian.
You. "You," "Your," or "Yours" means the Party to this Agreement who is the Parent or Guardian of the Patient(s) listed in the registration form above and has signed this Agreement.

Agreement

Term. This Agreement will last for one year, starting on the date it is executed by both parties.
Renewal. The Agreement will automatically renew each year on the anniversary date of the Agreement unless either party cancels the Agreement by giving 30 days written notice of termination.
Termination. Either party can end this Agreement for any reason by giving 30 days written notice to the other, of intent to terminate.
Fees and Manner of Payment.
1. The Parties agree that the Patient is entitled to the Services described in Appendix A, in exchange for a periodic, monthly membership fee in amounts as described in Appendix B, available at canopypediatrics.com/pricing or accessdirectprimarycare.com/pricing.
2. The full monthly fee for the first month will be due upon execution of this Agreement. Thereafter the monthly fee shall be due on the first day of each month. If the membership start date occurs in the middle of a month, the monthly membership fee for the second month will be charged at a prorated rate on the basis of a thirty (30) day month.
3. The Parties agree that the required method of payment shall be automatic electronic payment through credit card, debit card, or auto draft ACH.
Early Termination.
1. If We cancel this Agreement before its termination date, We will refund the unused portion of your fees to You on a per diem basis.
2. If You cancel this Agreement before its termination date, we will review your account and either:
  1. refund the unused portion of your fees to You on a per diem basis; or
  2. If the fair market value of the Services which Member/Patients have received over the term of the Agreement (up to the date of early termination) is more than the amount of membership fees You have paid over the same time period, You shall reimburse the Practice in an amount equal to the difference between the fair market value of the Services received and the amount You paid in membership fees up until the early termination. The Parties agree that the fair market value of services is equal to the Practice's usual and customary fee-for-service charges. A copy of these fees is available upon request.
Email and Text Usage. By providing an e-mail address in the registration form above, You authorize the Practice and its staff to communicate with You by e-mail regarding the Patient's "protected health information" (PHI). Further, in providing a cell phone number in the registration form above and by acknowledging the checkbox on the corresponding consent question number 30 labeled "Communications", You consent to text message communication containing Patient's PHI through the number provided. You further acknowledge that:
1. E-mail and text message are not necessarily secure mediums for sending or receiving PHI, and there is always a possibility that a third party may gain access;
2. Although the Physician will make all reasonable efforts to keep e-mail and text communications confidential and secure, neither the Practice nor the Physician can assure or guarantee the absolute confidentiality of these communications;
3. Patient is responsible at all times for providing Practice with current, updated email, cell phone and other contact information.
4. You understand and agree that e-mail and text messaging are not an appropriate means of communication in an emergency, for time-sensitive problems, or for disclosing sensitive information. You understand and agree to call 911 or go to the nearest emergency room and follow the directions of emergency personnel. In an emergency, or a situation that could reasonably be expected to develop into an emergency.
Technical Failure. Neither the Practice, nor the Physician will be liable for any loss, injury, or expense arising from a delay in responding to Patient, when that delay is caused by technical failure. Examples of technical failures: (i) failures caused by an internet or cell phone service provider; (ii) power outages; (iii) failure of electronic messaging software, or e-mail provider; (iv) failure of the Practice's computers or computer network, or faulty telephone or cable data transmission; (iv) any interception of e-mail communications by a third party which is unauthorized by the Practice; or (v) Patient's failure to comply with the guidelines for use of e-mail or text messaging, as described in this Agreement.
Dispute Resolution. Each Party agrees not to make any inaccurate, or untrue and disparaging statements, oral, written, or electronic, about the other. We strive to deliver only the best of personalized patient care to every Member, but occasionally misunderstandings arise. We welcome sincere and open dialogue with our Members, especially if We fail to meet expectations and We are committed to resolving all Patient concerns.

Therefore, in the event that a Member is dissatisfied with, or has concerns about, any staff member, service, treatment, or experience arising from their membership in this Practice, the Member and Practice agree to refrain from making, posting or causing to be posted on the internet or any social media, any untrue, unconfirmed, inaccurate, disparaging comments about the other. Rather, the Parties agree to engage in the following process:
1. You shall first discuss any complaints concerns or issues with Dr. Homan; and
2. Dr. Homan shall respond to each of Your issues and concerns.
3. If, after such response, Member remains dissatisfied, the Parties shall enter discussion and attempt to reach a mutually acceptable solution.
Physician Absence. From time to time, due to vacations, conferences, illness, or personal emergencies, the Physician may be temporarily unavailable to provide the services referred to in Appendix A. In order to assist You in scheduling non-urgent visits, Practice will notify You of any planned Physician absences as soon as those dates are confirmed with Physician. In the event of an unplanned physician absence, The Practice shall make reasonable efforts to provide alternative coverage for Patients. Any treatment rendered by the substitute provider is not covered under this Agreement but may be submitted to Patient's health plan.
Change of Law. If there is a change of any relevant law, regulation or rule, federal, state or local, which affects the terms of this Agreement, the parties agree to amend this Agreement to comply with the law.
Fee Adjustments. In the event that the Practice finds it necessary to increase or adjust monthly fees before the termination of the Agreement, Practice shall give You 30 days written notice of any adjustment and if You do not consent to the modification, You shall terminate the Agreement in writing prior to the next scheduled monthly payment.
Severability. If any part of this Agreement is considered legally invalid or unenforceable by a court of competent jurisdiction, that part will be amended only to the extent necessary to render it legally enforceable. The remainder of the Agreement will stay in force as originally written.
Reimbursement for Services Rendered. If this Agreement is held to be invalid for any reason, and the Practice is required to refund fees paid by You, You agree to reimburse the Practice in an amount equal to the Fair Market Value of the medical services Patient received during the time period for which the refunded fees were paid. The Parties agree that the value of the services is equal to the Practice's usual and customary fee-for-service charges. A copy of these fees is available on request.
Amendment. Except as provided within, no amendment of this Agreement shall be binding on a party unless it is in writing and signed by all the parties, except for amendments made in compliance with Section 29, below.
Assignment. You may not assign this Agreement or any of the granted under it, to any third party.
Legal Significance. You understand that this Agreement is a legal document which assigns the parties certain rights and responsibilities. You also acknowledge that You have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.
Miscellaneous. This Agreement shall be construed without regard to rules requiring that it be construed against the drafter the Agreement, and the captions in this Agreement have no legal meaning and appear only for the sake of convenience.
Entire Agreement. This contains the entire agreement between the parties and replaces any earlier understandings and agreements whether they are written or oral.
No Waiver. The parties agree that at any time they may choose not to enforce duties or responsibilities required of the other Party under this Agreement. Such a choice shall not constitute waiver of the right to enforce those same duties or responsibilities in the future. The parties shall retain the right to enforce such terms again at any time.
Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Florida. All disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for the Practice in Tallahassee, Florida.
Notice. All required written notices, with the exception of paragraph 14, above, must be sent by first class U.S. mail; To the Practice: At the address first appearing above; To Patient: At the address entered into the online registration paperwork, or other address as may be updated from time to time. Notice as required under paragraph 14 may be also achieved through email transmission sent to the email address provided by the Party to be noticed.
No Submission of Claims to Third Parties. As a DPC practice, We may not submit a claim for payment to any third party payor (such as insurance plans), for any services We provide to You. Further we cannot provide "superbills" reflecting fee for service because, We are not a fee for service practice. It is Your responsibility to ascertain whether any fees paid under this Agreement are reimbursable to you by any third party payor, and to seek reimbursement for same.

Appendix A

Services

Medical Services. The following are the specific Medical Services included under this Agreement (as determined by the Physician to be medically appropriate):

Acute and non-acute office visits
Well child/baby checks
Complimentary newborn home visits: Three visits for Canopy Pediatrics and a single visit for Access Direct Primary Care
Annual physicals
Sports, camp, and school physicals
Chronic disease management
Ear Piercing
Breathing treatments (nebulizer or inhaler with spacer)
In house rapid strep testing (Adults $5)
In house flu testing (Adults $10)
In house RSV testing
In house urinalysis
Blood glucose
Pulse oximetry
Intravenous treatment for dehydration
ADHD treatment
Behavioral treatment
Removal of benign skin lesions/warts*
Removal of cerumen (ear wax)
Simple wound repair and sutures
Infant bladder catheterization
Ace wrap of musculoskeletal injuries
Frenotomy for tongue tie
Abscess incision and drainage*
Basic Vision testing
Drawing basic labs*
Labs and testing that cannot be performed in-house will be offered at wholesale or close to wholesale rates through select vendors.
The convenience of access to many commonly prescribed prescription medications at greatly reduced prices, dispensed on premises.
You are responsible for all fees associated with any imaging, laboratory testing, specimen analysis, etc. that is not done in-house and/or personally performed by Practice staff. You shall be advised of any additional charges in advance.

Non-Medical, Personalized Services. The Practice shall also provide Patient with the following non-medical services, which are complementary to our members in the course of care:

After Hours Access. The Practice shall endeavor to provide direct telephone access to the Physician seven days per week for guidance in regard to urgent concerns that arise unexpectedly after regular business hours (8AM through 5:30PM on Monday through Friday). Text messaging may be used when the Physician and Patient agree that it is appropriate.
E-Mail Access. You shall be given the Physician’s e-mail address to which non-urgent communications can be addressed. Such communications shall be dealt with by the Physician or other staff member in a timely manner. You understand and agrees that email and the internet should never be used to access medical care in the event of an emergency, or any situation that could reasonably develop into an emergency. Patient agrees that in this situation, when s/he cannot speak to the Physician immediately in person or by telephone, to call 911 or go to the nearest emergency medical assistance provider and follow the directions of emergency medical personnel.
Quick, Convenient Scheduling. When You contact the Practice prior to noon on a normal business day to schedule a same-day visit, every reasonable effort shall be made to schedule the visit on the same day. If this is not possible, made to schedule Patient’s visit shall be scheduled on following business day. However, regardless of the above, when possible, We will always schedule the Patient visit on the date requested.
Specialists Coordination. Physician shall coordinate with Patient’s medical specialists to assure continuity of care, and if necessary, shall assist in obtaining a referral for specialty care. You understand that fees paid under this Agreement do not include these specialist’s fees or fees due to any medical professional other than the Practice Physician.

Appendix B

Pricing is age-dependent.

Lapsed Memberships subject to a reactivation of three times age-based Membership Fee at time of reactivation.

Canopy Pediatrics (Dr. Homan) Pricing:

0-11 months: $195per month
1 to 2 years: $145 per month
2 to 4 years: $125 per month
5 years+: $95 per month

*Canopy Pediatrics has a maximum of $350 per month for all children in a family

Access Direct Primary Care (Dr. Sparks) Pricing:

adults 22 - 44 years-of-age: $75 per month
adults 45 - 64: $85 per month
adults 65 years-of-age and older: $95 per month
children (less than 22 years-of-age) with a parent member: $75 per month

*Access Direct Primary Care has a maximum of $300 per month for all children and adult parents (maximum two adult parents) in a family

26. Non-Participation in Insurance. You acknowledge that by checking the box at the beginning of this clause of the Agreement that you understand and agree that neither the Practice, nor its Staff, accept or participate in any health insurance or HMO plans or panels and panels, including government payors such as Medicare and Medicaid. We make no representation that the fees paid under this Agreement are covered by the Patient's health insurance or any other third-party payment plans. It is Your responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan or HSA and to submit any required documentation and/or reimbursement requests.

27. Dr. Sparks is opted out of Medicare. You understand that Dr. Sparks is opted out of Medicare. Therefore, it the law prohibits any party from submitting charges to Medicare for services rendered by Dr. Sparks under this Agreement. Accordingly, You agree that shall not attempt to be reimbursed for or submit charges to Medicare for any services which we personally provide. You further agree to notify the Practice if You are or become, a Medicare beneficiary or Medicare eligible, and to sign a Medicare private contract agreement as required by law.

28. This Is Not Health Insurance. By checking the box at the beginning of this clause, you acknowledge your understanding that this Agreement is neither an insurance plan nor a substitute for health insurance. Furthermore, You understand that this Agreement does not replace any health insurance or health plan coverage that You now carry. You understand that this Agreement does not include hospital services, or any other services, procedures or products not personally provided by the Practice, or its staff. You acknowledge that We have advised You to obtain or keep in full force, health insurance that will cover the Member Patients for hospitalizations, catastrophic events, and all other healthcare needs not personally delivered by the Practice staff.

29. Communications. The Practice endeavors to provide You with the convenience of a wide variety of electronic communication options. We also take Your privacy seriously and are careful to comply with patient confidentiality requirements. However, communications through e-mail, facsimile, video chat, cell phone, text messaging and other electronic means, can never be absolutely guaranteed as secure or confidential methods of communication. By checking the box at the beginning of this clause, You understand and acknowledge the above and You agree that by initiating or agreeing to participate in the above means of communication, you expressly waive any guarantee of absolute confidentiality with respect to their use. You further understand that participation in the above means of communication is not a condition of membership in this Practice and that you a have the option to decline any means of communication.

30. State Required Disclosure. This agreement is not health insurance and the primary care provider will not file any claims against the patient's health insurance policy or plan for reimbursement of any primary care services covered by the agreement. This agreement does not qualify as minimum essential coverage to satisfy the individual shared responsibility provision of the Patient Protection and Affordable Care Act, 26 U.S.C. s. 5000A. This agreement is not 75 workers' compensation insurance and does not replace an employer’s obligations under chapter 440.

Date:

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Join Canopy Pediatrics or Access Direct Primary Care

Part of the Innovative Care Group

How to Complete the Registration: Please send us a text or give us a call if you need help (contact either one of us).

If you are registering as a family, please enter a parent's information as the first patient.

Patient Information

Enroll with:

Parent Information

Contact Information Same as Parent

Home Address

Emergency Contact Use Parent's Info

Set Username and Password for Patient Portal

Get a copy of your paper or electronic medical record

Correct your paper or electronic medical record

Request confidential communication

Ask us to limit the information we share

Get a list of those with whom we've shared your information

Get a copy of this privacy notice

Choose someone to act for you

File a complaint if you believe your privacy rights have been violated

In these cases, you have both the right and choice to tell us what to share

In these cases we never share your information unless you give us written permission

In the case of fundraising

Treat you

Run our organization

Bill for your services

Help with public health and safety issues

Do research

Comply with the law

Respond to organ and tissue donation requests

Work with a medical examiner or funeral director

Address workers' compensation, law enforcement, and other government requests

Respond to lawsuits and legal actions

Electronic Access

Contact Information

Emergency Contact