This Membership Agreement, Including Consent for Remote and Experimental Treatment (this “Agreement”) is entered into by and between Synergy Health DPC (SHD) & Synergy Health Network LLC and you, the individual identified below (the Patient”), as of the date of signature or as of the date you first access Synergy Health DPC services:
Consent to Remote Diagnosis, Treatment and Education. I hereby consent to remote diagnosis, treatment and education by Synergy Health DPC through the use of synchronous and asynchronous audio and video communications technology commonly known as telehealth or telemedicine technology (collectively, “Telehealth Technology”). I acknowledge that diagnosis, treatment and education through the use of Telehealth Technology will involve collecting information, including protected health information, about me and my diagnosis, treatment and education, and that such information will be transmitted, reviewed and stored in compliance with applicable laws. I acknowledge that while Telehealth Technology may improve access to care and treatment outcomes, as with any technology-facilitated diagnosis, treatment and/or education, there are risks and results cannot be guaranteed. The risks associated with Telehealth Technology include, and are not limited to, technical problems and equipment malfunctions that may result in omission, loss or compromise of information necessary for my diagnosis, treatment or education and that such omission, loss or compromise of information may result in my injury or death. I understand it is my responsibility to clearly explain symptoms, medical/surgical history and allergies, and to provide any other information as needed for Synergy Health DPC’s treatment plan.
I acknowledge that diagnosis, treatment and education using Telehealth Technology requires my health information, including protected health information, to be transmitted through audio and video technology and that my health information may be lost, compromised and/or accessed by unauthorized persons during transmission. I understand that I have a right to withhold or withdraw my consent to the use of Telehealth Technology in the course of my care at any time, and that doing so may terminate my treatment by Synergy Health DPC if alternative communication methodologies are not available.
ALL SALES FINAL NO REFUNDS will be issued under any circumstances as we have limited appointment slots available. In the event that either side needs to cancel the appointment, it may be rescheduled at no charge. Failure to read and understand the terms of this agreement before you purchase is your responsibility.
Waiver and Release. ON BEHALF OF MYSELF AND MY RELATIVES, HEIRS, REPRESENTATIVES AND ASSIGNS I HEREBY WAIVE AND RELEASE ALL CLAIMS THAT I MAY HAVE NOW OR IN THE FUTURE AGAINST SYNERGY HEALTH DPC AND ANY OF IT PROVIDERS, EMPLOYEES, AND OR CONTRACTORS FOR DAMAGE OR LOSS IN CONNECTION WITH THE RISKS INHERENT IN DIAGNOSIS, TREATMENT AND/OR EDUCATION USING TELEHEALTH TECHNOLOGY, INCLUDING, BUT NOT LIMITED TO, MEDICAL TREATMENTS, ADVICE, EDUCATION, TECHNICAL PROBLEMS, EQUIPMENT MALFUNCTIONS, AND OMMISSION, LOSS, COMPROMISE OR UNAUTHORIZED ACCESS TO HEALTH INFORMATION TRANSMITTED THROUGH TELEHEALTH TECHNOLOGY.
I understand and agree to the forgoing and all of my questions regarding its content have been answered. By signing below or accessing Synergy Health DPC services, I accept and agree to all of the above.
Waiver, Release and Consent to Experimental Treatment, including in Connection with COVID-19 and COVID-19 Variants. COVID-19 is a virus that is not yet fully understood. Risks of COVID-19 infection are believed to include, but are not believed to be limited to, sickness, injury, and death. To date, the United States Food and Drug Administration has not approved a treatment for COVID-19, and all treatments are therefore experimental.
I hereby consent for Synergy Health DPC and its licensed providers to attempt to treat my health condition, including COVID-19 infection, or to attempt to reduce the likelihood of COVID-19 infection, using experimental treatments and education. I understand that it is not possible to predict all possible side effects or complications associated with receiving such treatment(s) and/or education. The anticipated risks and benefits associated with the experimental treatments and/or education have been explained to me and I understand them. I agree to seek immediate emergency medical care at a Hospital if a condition for which I am receiving experimental treatment, including COVID-19, worsens and otherwise upon the recommendation of Synergy Health DPC.
Synergy Health DPC protocols, medications, vitamins do NOT CURE, TREAT, or PREVENT COVID-19. If you are experiencing a medical emergency, dial 911 or visit your closest Emergency Room. There are no guarantees that the treatments and or advice Synergy Health DPC offers and or administers will treat, prevent or cure COVID-19 or any other illnesses, diseases or syndromes the patient may contract or has contracted.
ON BEHALF OF MYSELF AND MY RELATIVES, HEIRS, REPRESENTATIVES AND ASSIGNS I HEREBY WAIVE AND RELEASE ALL CLAIMS THAT I MAY HAVE NOW OR IN THE FUTURE AGAINST SYNERGY HEALTH DPC ITS PROVIDERS, EMPLOYEES, AND OR CONTRACTORS FOR DAMAGE OR LOSS IN CONNECTION WITH THE RISKS INHERENT IN EXPERIMENTAL TREATMENT AND/OR EDUCATION, INCLUDING FOR COVID-19, AND INCLUDING, BUT NOT LIMITED TO, SICKNESS, INJURY OR DEATH.
Acknowledgement of Receipt of HIPAA Notice of Privacy Practices and Consent to Communications by Text Messaging.
I acknowledge that I have received a copy of Synergy Health DPC’s Notice of Privacy Practices. The Notice of Privacy Practices provides information about how Synergy Health DPC may use or disclose my health information. I consent to Synergy Health DPC communicating with me by phone, email and/or text messaging to manage appointments
ACCESSING SYNERGY HEALTH DPC SERVICES CONSTITUTES CONSENT TO THE TERMS AND CONDITIONS OF THIS AGREEMENT. By accessing, using and/or otherwise participating in Synergy Health DPC services, you acknowledge and agree to the terms and conditions of this Agreement.
Non Member Services are limited to the duration of the terms of the visit
Emergency Visits These visits are non refundable, and are not applied toward cost of care passes.
Care Pass Patients will receive Unlimited visits with our healthcare team for the duration of the care pass. Care Passes are NOT REFUNDABLE for any situation. Your verbal authorization is considered same as written authorization. Once you agree to the Care Pass all sales are final. In the event you go to the hospital we will continue to call you/family for the duration of the Care Pass term to satisfy our agreement. In the event we can not reach you during the term of the care pass day are not refundable or extendable
Term The term of this membership shall be for a term of 36 months. Membership will automatically renew at the end of the term unless a written notice of cancellation is provided within 30 days of the renewal date
Termination Members may choose to terminate their Synergy Health DPC Membership at any time and for any reason, byproviding written notice to Synergy Health DPC. There is a minimum monthly term commitment that you agree to.
● DPC Membership: MINIMUM TERM of 3 months.● Express Membership: MINIMUM TERM of 6 months.
In the event the member chooses to terminate before the minimum term is up they agree to be charged the difference in full upon termination. Termination will take effect at the end of the month in which notice is received. Until a written termination notice is received by Synergy Health DPC, membership fees will continue to be my responsibility. Fees that have been paid for membership will not be refunded.
Member Services The services provided pursuant to this Agreement (the “Services”) include the following:
Routine Medical Care. Unlimited routine medical visits as per Providers discretion. Routine medical care includes an annual physical, unlimited telehealth visits for medical conditions or ailments. Excluded are acute COVID care. I understand that the practice does not prescribe controlled substances.
Same Day or Next Day Sick Appointments. For sick visits the company will make reasonable efforts to see patients via Telehealth the same day or the day following the Patient’s request for such an appointment.
Medical Emergencies Entering into this Agreement is not a substitute for calling 911 in the event of a medical emergency. In the event of a life-threatening medical emergency, Patient should call 911 or go to the nearest emergency room. This practice does not provide emergency medical care
Patient Communication. Practice offers enhanced patient communication, which may include email, facsimile, video chat, instant messaging, and cell phone are not guaranteed to be secure or confidential methods of communications. As such, you expressly waive the Provider’s obligation to guarantee confidentiality with respect to correspondence using such means of communication. Practice offers a Secured Messaging App called Spruce to send and receive messages in a more secure form. In the event of an emergency, or a situation in which the member could reasonably expect to develop into an emergency, the patient shall call 911 or the nearest Emergency Room..
Responsibility for Charges I am responsible for the charges incurred for health care services. This includes, but is not limited to, all services provided by Synergy Health DPC and all other providers as well. It is my responsibility to pay all costs that are not covered by my membership fees.
Billing If I sign up for a membership, I understand that my fee is due monthly based on the effective date of my membership and covers the following month of service. In the event that I am unable to pay my fee(s) on time, I will notify Synergy Health DPC and attempt to find a solution. I understand that late payment may result in a late fee of up to $20 and that my membership may be terminated. If a Patient enters into this Agreement mid-month, then the Patient Services Fee will not be prorated.
Payment Authorization By providing a credit card or other payment method accepted by the company you are expressly agreeing that we are authorized to charge to the Payment Method any fees for your use of the Services, together with any applicable taxes. You agree that authorizations to charge your Payment Method remain in effect until you cancel it in writing, and you agree to notify the company of any changes to your Payment Method. You certify that you are an authorized user of the Payment Method and will not dispute charges for the Services. You acknowledge that the origination of ACH transactions to your account must comply with applicable provisions of U.S. law. In the case of an ACH transaction rejected for insufficient funds, the Company may at its discretion attempt to process the charge again at any time within 30 days.
Not Insurance I understand that Synergy Health DPC does not provide health insurance coverage and will not bill insurance carriers for any services. Also, I will not seek reimbursement from any insurance carrier for the medical services rendered by Synergy Health DPC.
Non-Participation in Insurance. Patients acknowledge that neither Practice nor Providers participate in any health insurance, health benefit plan, or HMO plans or panels. Patients also acknowledge that joining a Direct Primary Care (DPC) practice is a Private pay option. The practice does not do not accept Medicaid. Practice will not bill health insurance, a health benefit plan, Medicare, or Medicaid for the Services provided under this Agreement. This also applies to supplemental plans ultimately paid for by Medicare/Medicaid, including Medicare Advantage, Medicare Flex Plans, Medicare + Choice Plans, certain gap coverage plans, and recipients of benefits under Qualified Medicare Beneficiary Programs.
Medicare Beneficiaries. If Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, then Patient understands that the Practice and Providers do not accept Medicare for the services rendered at SHD. Patient’ understands Medicare cannot be billed for any services performed for the Patient by the Practice. By signing this agreement Patient agrees not to bill Medicare or attempt Medicare reimbursement for the Services.
No Medicaid Beneficiaries. Practice does not contract with Medicaid recipients to exchange Services for payment. Patient affirms by signing this Agreement that Patient is neither enrolled in Medicaid nor receiving Medicaid benefits, and Patient will not seek reimbursement or coverage from Medicaid related to any Services Patient receives.
Insurance or Other Medical Coverage. Patient acknowledges and understands that this Agreement is not an insurance plan or policy, and is not a substitute for health insurance or other health plan coverage (such as membership in an HMO or other health benefit plan). As such, this Agreement does not meet any individual health benefit plan mandate that may be required by federal law. This Agreement does not cover hospital services, or any services not personally provided by Provider.. Patient acknowledges that Practice has advised that Patient obtain or keep in full force such health insurance policy(ies) or health benefit plans that will cover the cost of health care services provided outside of this Agreement.
Severability. If a court of competent jurisdiction finds any provision of this Agreement unenforceable or invalid for any reason, that provision will be modified so that it complies with applicable law in its modified form, but the remainder of the Agreement will remain unaffected and enforceable.
Counterparts, Electronic Signatures. This Agreement may be executed in counterparts, each of which shall be deemed an original, but all of which together shall be deemed to be one and the same agreement. This Agreement, including may be accepted, executed or agreed to through the use of an electronic signature, with such electronic signatures having the same legal effect as original signatures. A signed copy of this Agreement recorded electronically, or delivered by scan, facsimile, e-mail, or other means of electronic transmission, shall be deemed to have the same legal effect as delivery of an original signed copy of this Agreement.
Acceptance Signatures. By signing below, Practice and Patient represent that they fully understand and freely covenant to accept the rights and obligations under this Agreement. Specifically, Patient, or Patient’s legal representative, represents that he or she has had the opportunity to review the Agreement thoroughly and discuss any and all questions.
DISCLAIMER OF WARRANTIES; LIMITATION OF LIABILITY YOUR USE OF THE SERVICES IS AT YOUR OWN RISK. THE SERVICES ARE PROVIDED “AS IS” WITHOUT WARRANTIES OF ANY KIND, EITHER EXPRESS OR IMPLIED, INCLUDING WITHOUT LIMITATION WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, OR OTHER VIOLATION OF RIGHTS. WE DO NOT WARRANT THE ADEQUACY, CURRENCY, ACCURACY, LIKELY RESULTS, OR COMPLETENESS OF THE SERVICES OR ANY THIRD-PARTY SITES LINKED TO OR FROM THE SERVICES, OR THAT THE FUNCTIONS PROVIDED WILL BE UNINTERRUPTED, VIRUS-FREE, OR ERROR-FREE. WE EXPRESSLY DISCLAIM ANY LIABILITY FOR ANY ERRORS OR OMISSIONS IN THE CONTENT INCLUDED IN THE SERVICES OR ANY THIRD-PARTY SITES LINKED TO OR FROM THE SERVICES. SOME JURISDICTIONS MAY NOT ALLOW THE EXCLUSION OF IMPLIED WARRANTIES, SO SOME OF THE ABOVE EXCLUSIONS MAY NOT APPLY TO YOU.
INDEMNIFICATION YOU AGREE TO INDEMNIFY, DEFEND AND HOLD US AND OUR PARENTS, SUBSIDIARIES, AFFILIATES, LICENSORS, SUPPLIERS AND THEIR DIRECTORS, OFFICERS, AFFILIATES, SUBCONTRACTORS, EMPLOYEES, AGENTS, AND ASSIGNS HARMLESS FROM AND AGAINST ANY AND ALL LOSS, COSTS, EXPENSES (INCLUDING REASONABLE ATTORNEYS’ FEES AND EXPENSES), CLAIMS, DAMAGES AND LIABILITIES RELATED TO OR ASSOCIATED WITH YOUR USE OF THE SERVICES AND ANY ALLEGED VIOLATION BY YOU OF THESE TERMS. WE RESERVE THE RIGHT TO ASSUME THE EXCLUSIVE DEFENSE OF ANY CLAIM FOR WHICH WE ARE ENTITLED TO INDEMNIFICATION UNDER THIS SECTION. IN SUCH EVENT, YOU SHALL PROVIDE US WITH SUCH COOPERATION AS WE REASONABLY REQUEST
MISCELLANEOUS. I expressly agree that this Agreement is intended to be as broad and inclusive as is permitted by applicable laws, and that if any portion of this Agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. This Agreement contains the entire understanding of the parties relating to the subject matter, and shall not be altered, amended, waived or supplemented in any manner whatsoever except by a written agreement signed by both parties hereto or their duly authorized representatives. This Agreement may be executed, made and delivered electronically. To the maximum extent permitted by applicable law and I, knowingly and voluntarily hereby waive any right to trial by jury with respect to such issue to the extent that any such right exists now or in the future. I certify that I have read this document and that I understand and agree to all of the foregoing information, terms, and conditions.
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Document Name: Consent
Agree & Sign