This Agreement outlines the terms of your Ultimate Weight Journey program (the "Program") offered by true Women’s Clinic of Grand Rapids, PC (the “Practice”).
The Program is designed with you in mind and to provide you Personalized Care Enhancements (“Enhancements”) including convenient access to the true. Team (“Team”) and Professional Medical Services.
By signing this Agreement, you agree to pay the Practice the 12 week fee ($1200). You further understand that this is not covered by your health insurance plan; and the Practice will not seek reimbursement from Medicare or any other health insurance plan for these services.
You have a right to request that the health care services be performed by a provider that participates with your health benefit plan, and may contact your carrier to arrange for those services to be provided at a lower cost and to receive information on in-network providers who can perform the health care services that you need.
Payment Terms: Your initial Fee (One-time payment ($1,200) s due at the time you sign this Agreement. You understand and agree that this Agreement is a service contract and not a contract of insurance, and you understand that you are not required to enter into this Agreement. You further agree not to submit a claim to any commercial or government health insurance plan (including Medicare) for any of the services. While you may, in your discretion, submit the Fee for reimbursement to a flexible spending account, health reimbursement account, or medical savings account in which you participate, the Practice makes no representation that any part of the Fee will qualify to be reimbursed from any such account.
You authorize the Practice and the Team to communicate with You by e-mail regarding your “protected health information” (“PHI”) (as that term is defined in the Health Insurance Portability and Accountability Act (“HIPAA”) of 1996 and its implementing regulations) using Your e-mail address shown below. In so agreeing, You acknowledge that: e-mail is not a secure medium for sending or receiving PHI; although the Practice and the Team will make reasonable efforts to keep e-mail communications confidential and secure, neither the Practice, nor the Team, can assure the confidentiality of e-mail communications; and, in the discretion of the Practice and/or your Physician, e-mail communications may be made a part of Your permanent medical record.
You agree that the Agreement and the terms and conditions defined in the Agreement shall be governed and interpreted under the laws of the State of Michigan, and that any actions or disputes shall be filed and maintained in the appropriate court within Kent County. This Agreement reflects the entire Agreement between You and the Practice as it relates to the Enhancements.
I have received, read, and understand this disclosure.