WELLINGTONMD PRIVATE PRACTICE PATIENT AGREEMENT

This Private Practice Patient Agreement ("Agreement") specifies the terms and conditions under which, you, the undersigned patient ("Patient") may voluntarily elect to participate in the healthcare offerings offered by WellingtonMD, LLC, a Florida professional limited liability company ("Practice") summarized as follows:

Practice makes available to Patient a diagnostic annual routine physical exam that is provided regardless of medical condition or necessity, coupled with ongoing follow-up for virtual/telehealth or in-office exams in support of the annual routine exam (all routine exams collectively "Annual Exam"), supported by a medical information plan that delivers ongoing Patient education and support toward health goals based on the Annual Exam ("Health Data Plan"), uniquely tailored to the Patient's personal issues, lifestyle and health goals. The Annual Exam and Health Data Plan are collectively "Services." Patient and Practice shall each also be individually called "Party" and collectively as the "Parties." Services are described in more detail in the attached Schedule A.

 SERVICES AND BENEFITS
The subscribing Patient shall pay the voluntary subscription fees referenced in the attached Schedule A ("Services Fees") for Practice to make Services available. The Services Fees compensate Practice for making the Services available. Practice reserves the right to update Schedule A.

PAYMENT OPTIONS
Patients may pay the Services Fees with a check or credit card payable to WellingtonMD, and with automatic Agreement renewals Practice is authorized to charge Patient's credit card on file for renewal term Service Fees.

RENEWALS AND TERMINATION
This Agreement will automatically renew one (1) year from the date of this Agreement unless terminated by either Party by written notice given to the other. The Practice may terminate this Agreement with thirty (30) days' prior written notice, in which case, the Patient will receive a prorated refund of the Services Fees for undelivered Schedule A Services but delivery of the Annual Exam fully earns all Service Fees paid. Patient may terminate this Agreement with thirty (30) days' written notice, stating the Patient's reason for termination, to receive a prorated refund of Service Fees for undelivered Services but delivery of the Annual Exam fully earns all Services Fees paid.

HEALTH CARE SERVICES THAT ARE OUTSIDE SERVICES AND SERVICES FEES
The Services Fees cover only the availability of Services subscribed to by Patient. If the Practice provides services other than the Services listed in Schedule A, Patient and Practice may mutually agree upon any additional charges, if any, to the extent the Patient's healthcare insurance plan ("Plan") does not cover those services. Patient acknowledges that either Patient or Patient's Plan may be responsible for any applicable additional charges for services outside of those described in Schedule A. Any charges to Patient for any services outside of Plan coverage and not reflected in Schedule A will be at Practice's usual, reasonable, and customary rates and consented to in advance by Patient. Practice will collect any applicable co-payments or deductibles related to Plan-covered services the Practice delivers to the Patient to the extent that the Practice is in-network with the applicable Plan.

ELECTRONIC PRACTICE COMMUNICATIONS
If Patient wishes to electronically communicate with Practice, Patient must know that electronic communication is not a secure medium for sending or receiving sensitive personal health information ("PHI"). Practice will take steps to keep Patient's electronic communications confidential and secure. Patient acknowledges and understands that electronic communications such as email are often not a good medium for urgent or time-sensitive communications as Practice anticipates a roughly thirty-six (36) hour response time for emails (see your plan details for limits on email communications). In the event the communication is time-sensitive, Patient must communicate with Practice by telephone or in-person. In any emergency please secure immediately emergency room/ER medical attention. Please refer to the separate Electronic Communications Agreement for further applicable details in this regard, which this reference is integrated herein. 

APPOINTMENTS, SCHEDULING & SCOPE OF SERVICES
The Patient will schedule Annual Exam and related services through electronic communications with the Practice. If Patient has an urgent concern related to Annual Exam health questions or concerns, Patient shall contact the Practice, but in any emergency Patient must call 9-1-1, utilize emergency medical services available outside Practice, or both. Services are designed to incorporate and provide primary care via the Annual Exam supported by the Health Data Plan Services, but Services Fees do not pay Practice for any healthcare or services other than the Services referenced in Schedule A.

MEDICARE
If Patient is or becomes Medicare eligible, Patient acknowledges that Practice is a participating Medicare provider, and under applicable federal regulations, Practice will submit reimbursement claims to Medicare for all Medicare-covered services Practice provides to Patient. Patient will not submit to Medicare any claim for payment of Services Fees or request that Practice submit such a claim for Services. Patient acknowledges and understands that Medicare will not cover or reimburse for the Services referenced in Schedule A.

VACATIONS AND ILLNESS FOR PRACTICE HEALTHCARE PROFESSIONALS
Patient acknowledges that there may be times that Patient cannot contact the Practice healthcare professional due to vacations or illness, Practice healthcare professional continuing medical education, or technical defects with either Patient's or Practice's electronic communication equipment. Should a Practice healthcare professional become unavailable, Patient acknowledges that Practice shall make every effort to give advance notice to Patient so that Services can be scheduled or delivered on another date. In cases of emergency, the Practice will offer contact information for a covering healthcare professional provider.

COMPLIANCE WITH LAW
Practice agrees to make Services available for Services Fees with the intent to comply with all applicable laws. The laws of the state in which Practice is located shall govern and construe this Agreement without application of choice-of-law principles. If there is a change of any law, regulation or rule, federal, state or local, which affects the Agreement or the activities of either Party under the Agreement, or any change in judicial or administrative interpretation of any such law, regulation, or rule, this Agreement shall be deemed modified so as to remain in compliance with such laws.

PRACTICE IS NOT AN INSURER
Practice is not an insurance company and is not promising or delivering unlimited care or services for the Services Fees. Practice presumes that Patient is either eligible for Medicare or otherwise has a private or public Plan that provides health care coverage for essential healthcare services not covered by Services Fees.

AGREEMENT ASSIGNMENT AND MODIFICATIONS
This Agreement may not be assigned to any other person by Patient or Patient's parent or legal guardian. This Agreement replaces and supersedes all prior agreements of any kind, oral or in writing, between Patient and Practice. This Agreement may not be modified absent a writing signed by Patient and an authorized representative of Practice.
By signing below, Patient agrees to subscribe to Services under the terms of this Agreement as detailed above and in Schedule A.

Practice makes available to Patient one (1) routine in-office diagnostic annual physical exam that is provided regardless of medical condition or necessity, supported by follow-up virtual/telehealth or in-office routine exams (all routine exams collectively "Annual Exam"), and supported by a medical information plan that stores Annual Exam health data and facilitates Practice/Patient communications related to the Annual Exam that delivers ongoing Patient education and support toward Annual Exam-based health goals ("Health Data Plan"), uniquely tailored to the Patient's personal issues, lifestyle, and health goals (the Annual Exam and Health Data Plan are collectively "Services"). The Annual Exam includes diagnostic focus on the following conditions:

• Comprehensive overview of your medical history, family history, and surgical history
• General health - including labs (billed to Plan to extent Practice in-network or authorized), vitals, and vision
• Whole body preventative/cardiovascular health - incorporating technology aided screening methods
• Pulmonary health
• Cancer screening - including skin and mole mapping, and cancer marker testing
• Alzheimer's/dementia- objective memory testing
• Genetic risk analysis
• Diabetes screening
• Metabolic health - including state of the art labs personalized to your needs
• Men's/Women's health issues
• Lifestyle (exercise, nutrition, etc.)- including body composition measurements
• Mental health screening

Health Data Plan communications shall be through Practice's email, office phone, or Practice physician's personal cell phone (for after-hours emergency communications). Practice can arrange Facetime or Skype calls to fit Patient's schedule. You may have physician/hospital/home visits if needed. Patient will have access to medical records and documents through Practice's Health Data Plan portal. Between Annual Exams the Practice will collect medical records, review blood pressure tests, and collate lab results (stored in the Health Data Plan) to provide you with personalized results and an updated personalized prevention and health plan to integrate with your next Annual Exam.

Services Fees: $2,200/year (per patient with payment options available)

- Discounts will be made available for the following patients:
• Annual services fee payment in full
• Family members of 3 or more
• Hormone Replacement /Testosterone, Weight Loss, or Energy boosting program subscribers

Notes: Due to the smaller patient panel size of the Practice, Practice anticipates Patient will enjoy little or no wait times for electronic Practice communications and routine exam scheduling, and Practice's healthcare professionals will also have the extended time and availability to provide unhurried visits to support ongoing health guidance and education. Due to the Health Data Communication Plan, Patients will enjoy direct and immediate communication with Practice using an electronic communications portal designed to also achieve HIP AA/privacy compliance.

For Medicare/Medicaid eligible patients, and with respect to any services other than the Services identified above, Practice may deliver services specifically covered by applicable Plan at Patient's request and as medically indicated and consistent with those Plan's reimbursement requirements. Medicare patients may request and receive the Welcome To Medicare Checkup, the Annual Wellness Visit, and chronic care management/CCM services-such services are not part of the private fee Services identified above and not provided for Services Fees. Any services covered by any applicable Patient Plan are not the private fee Services outlined above, and, such additional Plan-covered services can and will be provided by Practice as indicated and billed to the applicable Plan to the extent Practice is in-network with such Plan. Applicable Plan-required co-payments and deductibles will be collected as required by Plan terms. Patient will enjoy communications and visits from Practice's healthcare professionals that are neither hurried nor restricted by Plan coverage/reimbursement requirements. In no event may Patient submit to Medicare or Medicaid any private fee paid for Services and/or Services Fees, as Services are NOT covered or reimbursed by Medicare or Medicaid

WellingtonMD, LLC, a Florida professional limited liability company ("we", "us" or "Practice"), and the undersigned patient (''you" or "Patient") enter into this Electronic Communications Agreement ("EC Agreement") regarding the use of e-communications/transmissions, such as e-mail, mobile or cellular telephone, Skype, FaceTime, internet portal-enabled communications, or any other version of electronic communication ( collectively "E-Communication") with respect to Patient protected health information ("PHI"). (Practice and Patient are each individually called "Party" or collectively as "Parties").

PATIENT AUTHORIZATION DESPITE RISKS OF PRIVACY BREACH
While Practice and Patient commonly rely on electronic communication platforms and services to achieve immediate communication, there are risks that you acknowledge that are outside the Practice's control. You authorize all forms of E-Communications exchanged between Parties unless you instruct us otheiwise in writing. You acknowledge that the use of E-Communication is inherently risky and prone to unintentional release of data. E-Communications may incorporate or communicate references to your PHI with sensitive health and personal identification information included. You acknowledge that E-Communications lack any absolute guaranty of privacy and are subject to: system privacy failure, cookies and other tracking efforts, phishing attacks, hacking attacks, data breaches, unintended misdirections, misidentifications of senders/recipients, technology failures, and user errors.
You agree to undertake efforts to protect your privacy, which include refraining from including sensitive information in E-Communications that you do not want to be at risk of any data security breach. Practice will undertake reasonable efforts to protect your privacy to the extent required by applicable laws. You authorize us to respond electronically to all E-Communications that appear to be provided by you, whether or not such communications arrive from the electronic contact information that you provide us.

PATIENT MUST PROVIDE ACCURATE and UPDATED CONTACT INFORMATION

You agree to provide us with your accurate electronic contact information (mobile telephone number for phone calls and text messaging, email address, Skype or FaceTime contact information, and any other applicable E­Communication contact information). You will immediately inform us of any changes or corrections to your electronic contact information as an effort to avoid misdirected E-Communications.

PATIENT MUST NOT RELY ON ELECTRONIC COMMUNICATION IN EMERGENCIES:
USE 911 AND GET TO THE EMERGENCY ROOM
Practice does not guarantee that we will read your E-Communications immediately or within any specific amount of time. You agree not to utilize E-Communications to contact us regarding an emergency or time-sensitive situation, as there is too much risk that the communication response may be delayed, ineffective, untimely, or inadequate. You MUST call 9-1-1 in an emergency, immediately seek emergency medical attention, or both.

PRACTICE WILL COMPLY WITH IDPAA
The Practice values and appreciates your privacy and will take commercially reasonable steps to protect Patient's privacy in compliance with the Health Insurance Portability and Accountability Act of 1996 and related laws ("HIP AA").

We will obtain your express written or electronic consent (to the extent required by applicable law) if we are required or requested to foiward your identifiable PHI to any third party other than as authorized in our Notice of Privacy Practices or as authorized or mandated by applicable law.

You hereby consent to the use of E-Communication of Patient's information as we consider it helpful to coordinate care and schedule mobile visits with you and all those responsible for providing or overseeing your care. You agree to identify individuals or entities authorized to receive your PHI from us in connection with authorized consulting, education, and all other aspects of your care, and we may share your PHI with such parties without additional written or electronic consent from you.

You have the right to ask us for a copy of your PHI, including an explanation or summary. These services that we perform will not be the subject of additional charges to you: maintaining PHI storage systems; recouping capital or expenses for PHI data access, PHI storage, and infrastructure; or retrieval of PHI electronic information.

We may charge you fees for actual costs that we incur to provide such electronic PHI, but only to the extent authorized by applicable laws. Such fees may include, to the extent lawful: skilled technical staff time spent to create and copy PHI; compiling, extracting, scanning, and burning PHI to media and distributing the media (with media costs charged to you); and time spent by our administrative staff preparing additional explanations or summaries of PHI. If you request PHI on a paper copy, or portable media (such as compact disc/CD, or universal serial bus/USB flash drive), we may charge you for our actual supply costs for such equipment, and you agree to pay us any such costs.

PATIENT ACCEPTS RESPONSIBILITY FOR ELECTRONIC COMMUNICATION RISKS
You will hold Practice ( and our owners, officers, directors, agents, and employees) harmless from and against any and all demands, claims, and damages to persons or property, losses, and liabilities, including reasonable attorney fees arising out of or caused by E-Communication ( whether encrypted or not) losses or disclosures caused by any of the risks outlined above, by some person or entity other than Practice, or not directly caused by us. Patient acknowledges and understands that, at our discretion, E-Communication may or may not become part of your permanent medical record. These terms do not relieve Practice from Practice's obligations to comply with all applicable E-Communication laws.

You acknowledge that your failure to comply with the terms of this EC Agreement may result in our terminating the use ofE-Communication methods with you and may cause the termination of your agreement for our services.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
We are required to provide you a copy of our Notice of Privacy Practices, which states how we may disclose your health information. You hereby acknowledge receipt of the Notice of Privacy Practices.

CONSENT TO DISCLOSURE OF BILLING INFORMATION
By signing this EC Agreement, you consent to Practice disclosing all information relevant to billing, insurance, and reimbursement regarding any and all substance abuse disorders that you might have, for the purpose of obtaining reimbursement from private or public insurers.

ADDITIONAL TERMS
This EC Agreement will remain in effect until either Party provides written notice to the other Party revoking this EC Agreement or otherwise revoking consent to E-Communications between the Parties. Such revocation will occur thirty (30) calendar days after written notice of such revocation.
Revocation of this EC Agreement will preclude us from providing treatment information in an electronic format other than as authorized or mandated by applicable law or by you. Either Party may use a copy of this signed original EC Agreement for all present and future purposes.

Parties agree to take such action as is reasonably necessary to amend this EC Agreement from time to time as it is necessary for the Parties to comply with the requirements of the Privacy Rule, the Security Rule, and other provisions ofHIPAA, or other applicable law. Parties further agree that this EC Agreement cannot be changed, modified or discharged except by an agreement in writing and signed by both Parties.

If any term of this EC Agreement is deemed invalid or in violation of any applicable law or public policy, the remaining terms of this EC Agreement shall remain in full force and effect, and this EC Agreement shall be deemed amended to conform to any applicable law.

Each participating Patient (and authorized representative when applicable) must sign this EC Agreement. Your signature represents that you understand and agree to the terms and conditions described within this EC Agreement.

 

 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.

Dear Patient:

WellingtonMD, LLC, a Florida professional limited liability company ("we", "us", "our", "Practice"), understands that patient (''you", "your") privacy is important. This Notice of Privacy Practices ("Notice") applies to Practice and each of our Business Associates, as applicable.

Protected Health Information
Protected health information ("PHI") relates to information about you and your health, which could be used to identify you. Each time that you visit us, we create a medical record of your PHI and services that you receive.

Our Obligations Regarding Your Protected Health Information
We recognize that information about you and your health is confidential, and we are committed to protecting this information. This Notice applies to all your health records that we create.

We are required by law to preserve the privacy and security of your PHI. While there is no absolute guarantee of privacy, we are committed to protecting your privacy. We have established reasonable and appropriate measures to protect your PHI against unauthorized uses and disclosures.

Federal law mandates that we share this Notice with you, and that we make a good faith effort to obtain a signed document acknowledging your receipt of this Notice. We are also required to follow the terms of this Notice. In the event that we are involved in a breach of your PHI, we will immediately notify you.

Notice Effective Date and Potential Changes
This Notice became effective on December 1, 2020, and it applies to health records that we create for you. We reserve the right to change this Notice after the effective date. We can change the terms of this Notice, and the changes will apply to all the information we have about you. The new Notice will be available upon request.

How We May Disclose Your Protected Health Information
The laws of the state where Practice is located, and federal laws, allow disclosures of your PHI in some cases. Some of these disclosures do not require your verbal or written permission. The following information describes how we may share your PHI. We may typically use or share your PHI in these ways:

Treat you
We can use your PHI 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 PHI 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 PHI to bill and obtain 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.

Help with public health and safety issues
We can share your PHI for certain situations such as:

• Preventing disease;
• Helping with product recalls;
• Reporting adverse reactions to medications;
• Reporting suspected abuse, neglect, or domestic violence; and
• Preventing or reducing a serious threat to anyone's health or safety.

Perform research
We can use or share your PHI for health research.

Comply with the law
We will share your PHI if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

Respond to organ and tissue donation requests
We can share your PHI with organ procurement organizations.
Work with a medical examiner or funeral director.
We can share your PHI with a coroner, medical examiner, or funeral director when an individual dies.

Address other government requests
We can use or share your PHI:

• For workers' compensation claims;
• For law enforcement purposes or with a law enforcement official;
• With health oversight agencies for activities authorized by law; and
• For special government functions such as military, national security, and presidential protective services.

Respond to lawsuits and legal actions
We can share your PHI in response to a court or administrative order, or in response to a subpoena.

How else can we use or share your PHI?
We are allowed or required to share your PHI 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. We have not listed every use and disclosure in this Notice. For more information see: www.hhs.gov/ ocr/privacy/hipaa/understanding/ consumers/noticepp.html.

Use and Disclosure of Your Pm with Your Verbal Agreement
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 to:

• Share information with your family, close friends, or others involved in your care;
• Share information in a disaster relief situation; and
• Include your information in a hospital directory.

If you cannot 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 your health or safety.

Use and Disclosure of Your Pm Requiring Your Written Permission
If there are situations that have not been described above, we will obtain your written permission. In these cases, we never share your PHI unless you give us written permission:

• Marketing purposes;
• Sale of your information; and
• Most sharing of psychotherapy notes.

With fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again.

If you provide us with written permission, you may change your mind at any time. Please let us know in writing if you change your mind.

Your Rights Regarding Your PHI
You have the following rights regarding your PHI that is created in our Practice. This section explains some of your rights and our responsibilities to assist you.

Get an electronic or paper copy of your medical record

• You can ask to see or receive an electronic or paper copy of your medical record and other PHI that we have about you. Ask us how to do this.
• We will provide a copy or a summary of your PHI, usually within 30 days of your request. We may charge a reasonable cost-based fee.

Ask us to correct your medical record

• You can ask us to correct PHI about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say "no" to your request, but we will tell you why in writing within 60 days.

Request confidential communications

• 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 what we use or share

• You can ask us not to use or share certain PHI in connection with our services.
• We are not required to agree to your request, and we may say "no" if it would affect your care.
• Because you are privately paying for some medical or health services, you may ask us to refrain from sharing information related to those private pay services with your health insurance plan. We will respect that request unless we are legally obligated otherwise under applicable laws.

Get a list of who we have shared information

• You can ask for a list ( accounting) of the times we have shared your PHI 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, health care operations, and certain other disclosures (such as any you asked us to make).
• We will provide one accounting per 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 Notice

• You can ask for a paper copy of this Notice at any time, even if you have agreed to receive this 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.

Ask questions of file a complaint if you believe your rights are violated

• If you have questions about this Notice or you believe that your rights are being violated, please contact us immediately:

Practice Contact Information:

WellingtonMD
Attention: Dr. Brian Lipari 12989 Southern Blvd. Suite 103 Loxahatchee, FL 33470
Phone: (561) 268-2880
Fax: (561) 268-2881
Email: Office@wellingtonmd.com

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 A venue, S. W ., Washington, D. C. 20201, calling 1-877-696-677 5, or visiting www.hhs.gov/ ocr/privacy/hipaa/complaints.

Please provide as much information as possible so that the Department of Health and Human Services can thoroughly investigate your concern or complaint. We will not retaliate against you for filing a complaint with us, or the Department of Health and Human Services.

Thank you,

WELLINGTONMD

 

Notice to undersigned patient ("Patient"):

WellingtonMD, LLC, a Florida professional limited liability company ("Practice"), is required to provide Patient with a copy of Practice's Notice of Privacy Practices ("Notice"), which states how Practice may use and/or disclose Patient's health information.

Please sign this form to acknowledge receipt of the Notice.
You may refuse to sign this acknowledgment if you wish.

I acknowledge that I have received a copy of Practice's Notice of Privacy Practices.