This Agreement is entered by mutual voluntary consent.

This Patient Agreement (Agreement) is between Doc And Me Health (the Practice, Us or We), and (Patient, Member, or You).

Background

The Practice, located in Texas provides ongoing primary care medicine to its Members in a direct pay membership model (DPC). In exchange for certain periodic fees, the Practice agrees to provide You with the Services described in this Agreement under the terms and conditions contained within.

Definitions

1. Services.  In this Agreement, "Services" means the collection of services, medical and non-medical, which are described in Appendix A (attached and incorporated by reference), which We agree to provide to You under the terms and conditions of this Agreement.

2. Patient.  In this Agreement, "Patient," "Member," "You" or "Yours" means the persons for whom the Practice shall provide care, who have signed this Agreement, and/or whose names appear in appendix B (attached and incorporated by reference). 

Agreement

1. Term.  This Agreement will last for one year, starting on the date it is fully executed by the parties.

2. 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.  

3. Termination.  Either party can cancel this Agreement at any time by giving 30 days' written notice to the other of intent to terminate. 

4. Payments and Refunds: Amounts and Methods. 

5. In exchange for the Services described in Appendix A, You agree to a monthly payment (or Membership Fee) in the amount which appears in Appendix C, which is attached and incorporated by reference; 

6. Thereafter, the Membership Fee shall be due on the first business day of every month. 

7. The Parties agree that the required method of payment shall be by automatic payment through a debit or credit card or automatic bank draft. Patient understands and agrees to pay the monthly Membership Fee each month by the due date, via automatic debit or credit transaction using the payment information on file with Doc and Me Health. Patient acknowledges that a transaction declined due to insufficient funds or an expired debit or credit card may result in an additional fee of fifty-dollars for each late or missing payment ($50.00). If your membership is paid by a Plan sponsor, they are responsible for late or missing payments.

8. Member acknowledges that this Agreement requires the ongoing payment of a monthly Membership Fee. Membership is dependent on timely payment of this Membership Fee; and Member agrees and acknowledges that Membership Fees that are thirty (30) days past-due will result in the termination of this Membership Agreement and accordingly all services hereunder shall terminate as of the Termination date.

9. Changes In Fees: For memberships paid directly to the practice, the amount of the monthly Membership Fee may be changed at any time by the practice with prior notice. As always, the Member may cancel at any time subject to the termination terms of this Agreement if they are dissatisfied for any reason at all. Membership Fees paid prior to the date of notice of termination are non-refundable.

10. Early Termination.  If You cancel this Agreement before its term ends, We will refund any unused portion of your membership fee on a per diem basis. 

11. Any failure to comply with the terms outlined in this agreement will result in termination of this Agreement and membership with the Practice.

12. Upon termination, the Parties shall be released of all obligations under this Agreement, except that Member or Plan Sponsor shall remain responsible for any outstanding membership, service, or other fees of any type due prior to or incurred as a consequence of Member’s termination. Doc And Me Health shall be entitled to all amounts due by Member or Plan Sponsor

13. By signing for Membership Services, the Member hereby authorizes Doc and Me Health to initiate monthly charges to his/her credit card, debit card, or bank account for the Membership Fee, if applicable, plus any additional incidental costs incurred by the Member or the Practice on the Member’s behalf since the previous billing date. Member understands that his/her membership with the Practice is continuous and that, by signing below he/she authorizes recurring credit/debit or bank account charges unless paid by a Plan Sponsor. 

14. Non-Participation in Insurance.  The Practice does not participate with any health plans, HMO panels, or any other third-party payor.  As such, we may not submit bills or seek reimbursement from any third-party payors for the Services provided under this Agreement.

15. Medicare.   The Patient understands that the Practice and staff have not opted out of Medicare at this time. This means that the Practice is prohibited from entering into a private DPC healthcare agreement with current Medicare beneficiaries or enrollees. Until such time as the Practice formally terminates their Medicare provider agreement, all Medicare enrollees seeking to join the membership of this DPC will be put on a “call list”. As soon as the Practice receives written notification from CMS that the Practice’s Medicare provider agreement has been terminated, each individual on the call list will be contacted and informed that Medicare enrollees can now be accepted for DPC membership. If a current member of this DPC practice becomes eligible for Medicare during the term of this membership agreement, the Patient agrees to immediately notify the Practice

16. Non-Covered Services: The following (non-exhaustive) list of medical services are not covered by the monthly Membership Fee.  The practice will assist Member to obtain any of them, as needed, at special reduced pricing: X-rays, CT scans, ultrasound; outside office blood/other lab tests, even though some samples will be drawn in the office or a retail collection site at no charge; Any surgery or procedure not able to be performed in the the practice location (e.g. in a hospital, surgery center or specialist’s office); The cost of immunization drugs; Obstetrical care and delivery; Durable medical equipment and supplies (e.g. crutches, wheelchairs, walkers, canes, walking boots, casts, etc.); Prescription medications; and Intravenous, injectable or oral medication.

17. Costs Outside Of The Scope Of Agreement: The Member shall be able to secure many of the above ‘non-covered services’ at reduced prices or fees when coordinated through the Doc And Me Health team. All pricing is transparent, and your costs will be made clear before providing any non-covered good or service.  For example, discounted medications and laboratory services are offered through independent third-party vendors. Availability, pricing, and fulfillment are not guaranteed and may change without notice. In the event these services are modified or discontinued, patients may choose to use a pharmacy or laboratory of their choice at their own expense.

18. This Agreement Is Not Health Insurance.  The Patient has been advised and understands that this Agreement is not an insurance plan. It does not replace any health coverage that the Patient may have, and it does not fulfill the requirements of any federal health coverage mandate. This Agreement does not include hospital services, emergency room treatment, or any services not personally provided by the Practice or its staff. This Agreement includes only those Services identified in Exhibit A. If a Service is not specifically listed in Appendix A, it is expressly excluded from this Agreement. The Patient acknowledges that We have advised them to obtain health insurance that will cover catastrophic care and other services not included in this Agreement. Patients are always personally responsible for the payment of any medical expenses incurred for services not included under this Agreement.    

19. Communications.  The Practice endeavors to provide Patients with the convenience of a wide variety of electronic communication options. Although We are careful to comply with patient confidentiality requirements and make every attempt to protect Your privacy, communications by email, facsimile, video chat, cell phone, texting, and other electronic means, can never be absolutely guaranteed secure or confidential methods of communications. By placing Your initials at the end of this agreement, You acknowledge the above and indicate that You understand and agree that by initiating or participating 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; that you are not required to initial this clause;  and that you have the option to decline any particular means of communication.                                                                    

20. Email and Text Usage. By providing an email address on the attached Appendix B, the Patient authorizes the Practice and its staff to communicate with him/her by email regarding the Patient's "protected health information" (PHI).  By providing a cell phone number in Appendix B and checking the "YES" box on the corresponding consent question, the Patient consents to text message communication containing PHI through the number provided. The Patient further understands and acknowledges that:

21. Email and text message are not necessarily secure methods of sending or receiving PHI, and there is always a possibility that a third party may gain access;

22. Email and text messaging are not appropriate means of communication in an emergency, for dealing with time-sensitive issues, or for disclosing sensitive information. Therefore, in an emergency or a situation that could reasonably be expected to develop into an emergency, the Patient agrees to call 911 or go to the nearest emergency care facility and follow the directions of personnel.

23. Technical Failure.  Neither the Practice nor its staff will be liable for any loss, injury, or expense arising from a delay in responding to the Patient when that delay is caused by technical failure.  Examples of technical failures: (i) failures caused by an internet or cell phone service outages; (ii) power outages; (iii) failure of electronic messaging software, or email outages of physician; (iv) failure of the Practice's computers or computer network, or faulty telephone or cable data transmission; (iv) any interception of email communications by a third party which is unauthorized by the Practice; or (v) Patient's failure to comply with the guidelines for use of email or text messaging, as described in this Agreement.

24. Physician Absence.  From time to time, due to such things as vacations, illness, or personal emergency, the physician may be temporarily unavailable. When the date/s of such absences are known in advance, the Practice shall give notice to Patients so that they may schedule non-urgent care accordingly.  During unexpected absences, Patients with scheduled appointments shall be notified as soon as practicable, and appointments shall be rescheduled at the Patient's convenience. If during physician's absence, the Patient experiences an acute medical issue requiring immediate attention, the Patient should proceed to an urgent care or other suitable facility for care. Charges from Urgent Care or any other outside provider are not included under this Agreement and are the Patient's responsibility. The Patient may, however submit such charges to their health plan for reimbursement consideration or request that the outside provider do the same. The Patient is responsible for understanding the coverage rules of their health plan, and We cannot guarantee reimbursement. 

25. This Agreement is expressly limited to routine primary care services, and is NOT a medical insurance contract. Member acknowledges that Member does NOT have an emergency medical problem at this time. Member does NOT expect FPC to file or contest any third party insurance claims on his/her behalf. Member is voluntarily enrolling himself/herself (and/or family/dependents or employees, if applicable) as a Member.

26. 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 the 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: 

    Member shall first discuss any complaints, concerns, or issues with their physician; 

    The physician shall respond to each of the Member's issues or complaints;

    If, after such response, Member remains dissatisfied, the Parties shall enter into discussion and attempt to reach a mutually acceptable solution. 

27. Monthly Fee and Service Offering Adjustments. In the event that the Practice finds it necessary to increase or adjust monthly fees or Service offerings before the termination of the Agreement, the Practice shall give 30 days' written notice of any adjustment. If Patient does not consent to the modification, Patient shall terminate the Agreement in writing prior to the next scheduled monthly payment. 

28. Change of Law.  If there is a change of any relevant law, regulation or rule, which affects the terms of this Agreement, the parties agree to amend it only to the extent that it shall comply with the law.

29. Severability.  If any part of this Agreement is considered legally invalid or unenforceable by a court of competent jurisdiction, that part shall be amended to the extent necessary to be enforceable, and the remainder of the Agreement will stay in force as originally written. 

30. 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. 

31. Assignment.  Neither this Agreement nor any rights arising under it may be assigned or transferred without the agreement of the Parties.

32. Legal Significance.  The Patient acknowledges that this Agreement is a legal document that gives the parties certain rights and responsibilities. The Patient agrees that they are suffering no medical emergency and has had reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and is satisfied with the terms and conditions of the Agreement.

33. Miscellaneous.  This Agreement is to be construed without regard to any rules requiring that it be construed against the drafting party. The captions in this Agreement are only for the sake of convenience and have no legal meaning.

34. Entire Agreement.  This Agreement contains the entire Agreement between the parties and replaces any earlier understandings and agreements, whether written or oral.

35. No Waiver.  Either party may choose to delay or not to enforce a right or duty under this Agreement. Doing so shall not constitute a waiver of that duty or responsibility and the party shall retain the absolute right to enforce such rights or duties at any time in the future.    

36. Jurisdiction.  This Agreement shall be governed and construed under the laws of the State of Texas.  All disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for the Practice.

37. Notice.  Written Notice, when required, may be achieved either through electronic means at the email address provided by the party to be noticed or through first-class US Mail. All other required notice must be delivered by first-class US mail to the Practice at:  2245 Texas Dr, Suite 140, Sugar land, TX 77479 and to the Patient, at their address provided in Appendix B. 

The Parties agree that throughout this agreement and its attachments, checking the appropriate box next to their name will constitute an electronic signature and shall be valid to the same extent as a handwritten signature.                                                           

APPENDIX A

SERVICES

1. Medical Services

Medical Services offered under this Agreement are those consistent with the physician's training and experience, and as deemed appropriate under the circumstances, at the sole discretion of the physician. The Patient is responsible for all costs associated with any medications, laboratory testing, and specimen analysis related to these Services unless otherwise noted. The specific Medical Services provided under this Agreement include the following:

• Evaluation and management of acute, non-emergency medical conditions via video or virtual consultation

• Evaluation of non-urgent medical concerns suitable for telehealth

• Chronic disease management (e.g. diabetes, high blood pressure, asthma, heart disease)

• Preventive care

• Wellness virtual visits

• Weight loss counseling and medical guidance

• Smoking cessation

• Healthy Lifestyle Counseling

1. Non-Medical, Personalized Services. The Practice shall also provide Members with the following non-medical services: 

• After-Hours Access. Subject to the limitations of paragraph 14, Members shall have direct telephone access to the physician for guidance in regard to urgent concerns that arise unexpectedly after office hours.

• Email Access.  Subject to the limitations of paragraph 12, above, The Patient shall be given the physician's email address to which non-urgent communications can be addressed. The Patient understands and agrees that neither email nor the internet should be used to access medical care in the event of an emergency or any situation that could reasonably develop into an emergency. The 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 physician, and follow the directions of emergency medical personnel. 

• Same Day/Next Day Appointments.  When a Patient contacts the Practice prior to noon on a regular office day to request a same-day appointment, every reasonable effort shall be made to schedule the Patient for that same day; or if this is not possible, Patient shall be scheduled for the following office day (subject to the limitations of paragraph 14). 

• No Wait or Minimal Wait Appointments. Every reasonable effort shall be made to assure that the Patient is seen by the physician immediately upon arriving for a scheduled office visit or after only a minimal wait.  If physician foresees more than a minimal wait time, Patient shall be contacted and advised of the projected wait time. Patient shall then have the option of seeing the physician at the later time or reschedule at a time convenient to the Patient.

• Telehealth. Telehealth (virtual visits) will be available when desired and deemed appropriate by the Patient and physician.

• Specialists Coordination. The physician shall coordinate care with medical specialists and other practitioners to whom the Patient needs referral. The Patient understands that fees paid under this Agreement do not include specialist's fees or fees due to any medical professional other than the Practice staff. 

APPENDIX B

PATIENT ENROLLMENT FORM

CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION.  PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION.

THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING PATIENT(S), WHO BY SIGNING BELOW ( OR AS LEGAL REPRESENTATIVE), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT:

Patient agree to Text Communication.

APPENDIX C

FEE ITEMIZATION

Re-enrollment fee. 

If, after allowing membership to lapse or be terminated, Patient desires to re-join the practice, the Patient shall be accepted on a space-available basis, subject to a $199 re-enrollment fee.

APPENDIX D

Patient Notice and Consent

For use of AI Powered Medical Dictation and Transcription Tool

Notice:

During your patient visit, an AI powered medical dictation and transcription tool might be used to document details of your patient appointment with your Physician. This AI powered medical dictation and transcription tool is designed to improve the efficiency of your medical care.

Consent:

By signing this form, you are providing consent to the use of AI powered medical dictation and transcription tool in the processing and documentation of your health information during your medical consultation and care. You have the right to withdraw your consent at any time, which will not affect the quality, access or provision of your healthcare. Please ask your healthcare provider if you have any questions about AI powered medical dictation and transcription tool or about this form.

We encourage you to discuss any concerns you may have with your healthcare provider before signing this consent form.

By my signature below, I understand and consent to the above explanation regarding the use of an AI powered medical dictation and transcription tool, its uses, potential benefits, and I have had the opportunity to ask my healthcare provider questions, and all of my questions have been answered to my satisfaction. I hereby give my consent to my healthcare provider to use an AI powered medical dictation and transcription tool in the process and documentation of my healthcare information.

APPENDIX E

Consent to Treat, Telehealth & Communication, and Medical Photography

1. Consent to Medical Treatment

I voluntarily consent to outpatient medical evaluation and treatment provided by Doc and Me Health (the “Practice”). This may include, but is not limited to, medical history review, physical examinations, preventive care, diagnostic testing, laboratory services, medications, injections, and other non-emergency medical services deemed appropriate by the clinician.

I understand that the Practice provides non-emergency primary care services only and does not provide emergency or hospital care. In the event of a medical emergency, I understand that I should call 911 or go to the nearest emergency department.

2. Telehealth & Electronic Communication Consent

I understand that the Practice may provide care via telehealth, including video visits, secure messaging, phone calls, text messages, and email, when clinically appropriate and permitted by law.

I acknowledge that:

• Telehealth has limitations compared to in-person evaluation

• Electronic communications may not be completely secure

• Telehealth and messaging are not appropriate for emergencies or urgent conditions

By signing below, I consent to the use of telehealth and electronic communications for care coordination and medical services, consistent with applicable federal and Texas laws. I understand that I may withdraw this consent in writing at any time.

3. Medical Photography (Optional)

I understand that medical photographs may occasionally be useful for documentation, diagnosis, or treatment (for example, skin conditions or wounds). I consent to medical photographs being taken and stored in my medical record for clinical care purposes only.
I understand that photographs will not be used for marketing, education, or any purpose outside my medical record without my separate written authorization.

One-Time Visit Agreement

(Fee-For-Service)

This Agreement is entered by mutual voluntary consent.

1. Medical Consent: I consent to any medical treatments or procedures which may be performed on an outpatient basis (excluding emergency treatment or services), which may include but are not limited to medications, injections, taking of medical photographs, laboratory procedures, and/or x-ray examinations provided to me under the general and special instructions of the physicians, staff, or other health care providers of Doc and Me Health assisting my care.

2. Financial Obligation: I understand that all Fee For Service (FFS) charges are due at the time of service. I agree to pay Doc and Me Health  for all charges for healthcare services and professional services provided to me by physicians and other healthcare professionals. The Fee For Service charges are as follows:   

Acute care $199 per visit, follow up visit $149

3. Acceptable forms of payment include Visa, MasterCard, Discover and Debit card. If I am a non-insured patient, I agree to pay for my visit in full at the time of service.

4. Non-Participation in Insurance.  The Practice does not participate with any health plans, HMO panels, or any other third-party payor.  As such, we will not submit bills or seek reimbursement from any third-party payors for the Services provided under this Agreement.

5. Medicare.  The Patient understands that the Practice and staff have not opted out of Medicare. As a result, both the Patient and the Practice shall be prohibited by law from seeking reimbursement from Medicare for any  Services provided under this Agreement.

6. Release of Medical Information: I hereby authorize Doc and Me Health  to release any information in my chart to any practitioner, doctor, hospital, or medical institution to which I may be referred to assist in my care. Additionally, I authorize any request for medical information from any medical practitioner, doctor, hospital, or medical institution to assist in the care of the above-named patient.

7. The undersigned certifies that he/she has read and agreed to the above and foregoing, and received a copy thereof, and is duly authorized to enter this FFS agreement.