Patient Agreement

Last updated: May 1, 2019

CONSENT TO TREAT: By signing below, you acknowledge and agree that you have requested to receive medical treatment and services from Wellness 51 Doctors, and you consent to the rendering of medical treatment and services as considered necessary and appropriate by a Wellness 51 Doctors clinician at the time of the visit. You have the right to decline treatment and services at any time during the course of the visit but you may be responsible for paying for services already rendered. You also

acknowledge that no assurances or guarantees have been made to you by Wellness 51 Doctors or any of Wellness 51 Doctors clinicians concerning the outcome and/or results of any medical treatment or services.

SERVICES: Wellness 51 Doctors provides non-emergent, mobile and in office medical services at locations designated by its patients. Wellness 51 Doctors’ services include, acupuncture, wellness services, nutrition and mindfulness counseling,

Wellness 51 DOCTORS DOES NOT PROVIDE EMERGENCY MEDICAL CARE: If you have an emergency, such as chest pain, severe shortness of breath, severe headache or bleeding, call 911 or proceed directly to the nearest hospital emergency room.

Under certain limited circumstances, a Wellness 51 Doctors clinician may determine, in his or her best judgment, that he or she is unable to provide medical treatment and services to you, based on information received or conduct occurring during the course of a visit; provided, however, that in no case shall a Wellness 51 Doctors clinician make such a determination based on a patient’s sex, sexual orientation, race, creed, color, national origin or disability. If a Wellness 51 Doctors clinician determines he or she is unable to provide medical services after payment is made, Wellness 51 Doctors may refund all or a portion of the payment made, in its reasonable discretion.

PRESCRIPTION POLICY: Wellness 51 Doctors does not prescribe any narcotics, pain medications, or any other drugs designated as such by the United States Drug Enforcement Administration.

SUBSEQUENT CARE & COORDINATION WITH YOUR PRIMARY CARE PROVIDER: Wellness 51 Doctors are not your primary care provider, it is your sole responsibility to follow through with your primary care provider on any medical conditions or potential abnormalities detected or not detected by the visit, and to obtain a medical examination by your primary care provider related to the findings, or lack of findings, of this visit.

PATIENT RELATIONSHIP: A patient relationship with Wellness 51 Doctors or a Wellness 51 Doctors clinician is not established until you have actually been seen by a Wellness 51 Doctors clinician. To facilitate visit bookings and communications with its patients, Wellness 51 Doctors licenses access to a proprietary mobile- and web- based application (collectively the “Wellness 51 TM Application”). The Wellness 51 TM Application allows you to transmit a requests for services to Wellness 51 Doctors and provides the capability for Wellness 51 Doctors to respond and schedule the services. The use of the Wellness 51 TM Application alone does not create any patient relationship with Wellness 51 Doctors.

In addition, you acknowledge and agree that you have selected to receive services from Wellness 51 Doctors and that no third-party has referred, suggested or recommended Wellness 51 Doctors to you.

EQUITABLE ACCESS & NON-DISCRIMINATORY CARE POLICY: It is Wellness 51 Doctors’ policy make all commercially reasonable efforts to provide accommodations that will allow seniors and people with disabilities to request and receive equitable access and non-discriminatory medical care. As such, to the extent practicable and/or required by law, Wellness 51 Doctors’ practices align with the standards set by Section 504 of the 1973 Rehabilitation Act, the Americans with Disabilities Act, as amended (ADA), and other applicable state laws and regulations that prohibit discrimination on the basis of disability. You understand and agree that the practice’s mobile care delivery model means that Wellness 51 Doctors has no control over any physical accommodations at the specific locations where you may request and/or receive medical services.

PAYMENT FOR SERVICES: Wellness 51 Doctors generally charges on a fee-for-service basis for the services it provides, or by some other fee scheduled negotiated between Wellness 51 Doctors and certain contracted health plans (the “Service Fee”). Any Service Fees, or portion thereof, that is your financial responsibility must be made by credit card through the Wellness 51 TM Website or at a Wellness 51 clinic. When necessary to accommodate patients with disabilities, Wellness 51 Doctors may accommodate payment telephonically. If you are a member of an insurance plan that contracts with Wellness 51 Doctors as an in-network provider, and your insurance coverage has previously been verified, Wellness 51 Doctors will bill the insurance plan for the portion of the Service Fee for which it is responsible. Wellness 51 Doctors is not a participating medical practice in the Medicare Program and does not accept assignment for Medicare claims. If you are a Medicare beneficiary, Wellness 51 Doctors accepts the Medicare approved amount as full payment for covered services. You will be responsible for any applicable copayments or deductibles, and your credit card will be charged accordingly. WELLNESS 51 DOCTORS DOES NOT PARTICIPATE IN MEDICAID. BY SIGNING BELOW, YOU ACKNOWLEDGE THAT YOU ARE NOT A MEDICAID BENEFICIARY.

Please be aware that some – and perhaps all – of the services you receive may be noncovered or not considered reasonable or necessary by your health insurance plan. The balance of your claim is your financial responsibility, whether or not your health insurance plan pays your claim. It is your responsibility, as the insured, to determine if Wellness 51 Doctors is a network provider and how your benefits apply.

RETENTION OF RECORDS: Wellness 51 Doctors shall retain health care records for at least six (6) years after their receipt or production, unless a longer period is required by law (e.g., for records of minors). Wellness 51 Doctors may destroy health records once it is no longer required to retain them.

COORDINATION WITH HEALTH RECORDS AND HEALTH DATA: In an effort to gain a more complete picture of your health and help avoid unnecessary testing and duplicated efforts, Wellness 51 Doctors supports coordinating access to your health records and health data that may be created by various third-party sources before, after and/or in between your visit(s). This may include access to (1) your patient health records from other providers and/or (2) your electronic health data created by your use of different wellness, fitness or medical devices.

In an effort to streamline this coordination via wireless transmission, you can connect your account in the Wellness 51 TM Application with other third-party platforms and/or products that will share your information with the Wellness 51 TM Application once these services become available. Wellness 51 Doctors will be able to see any of your records and data that are shared with the Wellness 51 TM Application. Your information will only be shared with Wellness 51 Doctors in this manner as long as your account remains connected. Your decision to connect your accounts is completely voluntary and you may disconnect from third- party platforms or products at any time.

Because Wellness 51 Doctors is not affiliated with any applicable third-parties, it makes no promise that third-party platforms or products will be fault free. Further, Wellness 51 Doctors is not responsible for the accuracy of your health records or health data that are created by any third-parties.

ASSIGNMENT OF BENEFITS; AUTHORIZED REPRESENTATIVE: In exchange for and in connection with any and all of the service(s) provided to you by Wellness 51 Doctors, by signing below you hereby irrevocably and expressly request that payment of authorized insurance benefits be made on your behalf to Wellness 51 Doctors for services furnished to you. In addition, by signing below, you hereby designate Wellness 51 Doctors as your duly authorized representative in connection with all matters arising from or relating to the services provided, and you agree to cooperate with and take all steps necessary to effectuate, perfect, confirm or validate the assignment of benefits and/or authorization of Wellness 51 Doctors as your authorized representative, as addressed herein.

INDEMNIFICATION: By signing below, you acknowledge that you shall be liable for, and shall indemnify, defend and hold harmless Wellness 51 Doctors from any and all liability, loss, claim, lawsuit, injury, cost, damage or expense whatsoever (including reasonable attorneys’ fees and court costs) arising out of, incident to or in any manner occasioned by (1) the performance or nonperformance of any duty or responsibility by patient, (2) any tortious acts committed by you or any other person at your residence or other location of the visit, and (3) any damages resulting from any defects at your residence or location, but only to the extent, and only in such amount, that such liability, loss, claim, lawsuit, injury, cost, damage or expense is not covered and paid by third party insurance. The foregoing indemnification provision shall in all instances be deemed to be subordinate to any third-party insurance coverage that may cover all or any portion of any indemnification claim, including without limitation the patient’s homeowner’s insurance policy, as applicable.

DISCLOSURE OF PROVIDER INFORMATION & PATIENT GRIEVANCES: All Wellness 51 Doctors’ clinicians are licensed, certified or otherwise permitted to provide medical services in the state of where medical services are provided to you. Your treating clinician’s information, including name, highest level of academic degree, specialty, license status, and license number, and board certification (where applicable) are available through the state in which they are licenced.

Should you have any questions, comments, feedback or grievances concerning your treating clinician, Wellness 51 Doctors’ clinical team or other staff, and/or the treatment you received, you may always reach out directly to Wellness 51 Doctors at Support@Wellness 51.com.

Additionally, patients always have the right to report concerns or grievances to the appropriate state medical Board, or other applicable regulatory body. Wellness 51 Doctors provides you with information regarding how to contract such regulatory bodies in your “new patient” documents. You may, at any time, request that Wellness 51 Doctors provide you with that information again.

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

THE NOTICE OF PRIVACY PRACTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY, AS IT EXPLAINS:

• How Wellness 51 Doctors will use and disclose your protected health information.

• Your privacy rights with regard to your protected health information.

• Wellness 51 Doctors’ obligations concerning the use and disclosure of your protected health information.

You acknowledge that you have received a copy of Wellness 51 Doctors’ HIPAA Notice of Privacy Practices and have been provided an opportunity to review it, and consent to receipt of an electronic copy. You further acknowledge that Wellness 51 Doctors’ Notice of Privacy Practices is available from Wellness 51 Doctors upon request, and is available at https://www.Wellness51.com/privacy/.

CONSENT TO EMAIL AND ELECTRONIC COMMUNICATIONS

You consent to the use of unsecured email, mobile phone text message, or other electronic methods of communication (“E-messages”) between yourself and Wellness 51 Doctors, a Wellness 51 Doctors clinician, and any other Wellness 51 Doctors agents, for purposes of discussing personal material relevant to your treatment or health records. You understand that E-Messages are typically not confidential means of communication and that there is a reasonable chance that a third-party (including people in your home or other environments who can access your phone, computer, or other devices; your employer, if using your work email; and/or third parties on the Internet such as server administrators and others who monitor Internet traffic) may be able to intercept and see these messages. You have been informed of the risks—including but not limited to the risk with respect to the confidentiality of your treatment—of transmitting your protected health information by an unsecured means. You acknowledge that E-messages are not to be used in the case of an emergency, and that you should call 911 or proceed directly to the nearest emergency room.

DISCLOSURE OF PHYSICIAN INFORMATION (FOR CALIFORNIA ONLY)

You acknowledge that you have received information regarding the Wellness 51 Doctors physician’s name and license number, license status, highest level of academic degree, and board certification. The Wellness 51 Doctors physician is licensed to practice acupuncture in the state of California and may be a board certified or board-eligible physician, or a licensed physician in his/her final year of residency who is not yet board-certified or board eligible. You understand that you can contact the Acupuncutre Board of California at the below-listed telephone number and website should you have any questions or concerns.

NOTICE

Acupuncture doctors are licensed and regulated by the Department of Consumer Affairs of California

State of California

Acupuncture Board

1747 North Market Blvd, Suite 180

Sacramento, CA 95834

https://www.acupuncture.ca.gov/