1. Benefits of the functional medicine approach and scope of practice. I understand that Provider and his/her team use diagnostic and treatment methods that—in addition to conventional health care—are known as preventative, complementary, alternative, functional, naturopathic, or integrative medicine (collectively, “Functional Medicine”). In general, Functional Medicine may provide benefits that include relief of presenting symptoms and improved function that may lead to prevention, improvement, or elimination of the presenting symptoms, though no particular outcome can be warrantied or guaranteed. Functional Medicine focuses on nutritional and metabolic imbalances, diet, exercise, environmental influences, and psycho-social stressors based on the premise that they directly relate to the development and maintenance of illness. Functional Medicine evaluates these influences and then specifically tries to remedy them. It encourages patients to give up negative lifestyle patterns and establish more positive ones, regardless of the type of medical conditions for which they are seeking treatment.

2. Risks. I understand that, as with any health treatment, Functional Medicine is not without risk. Potential risks of treatment include, but are not limited to, allergic reactions, sensitivities, adverse effects from, or in response to, natural supplements or dietary measures, failure to improve or worsening of my condition, and difficulty adjusting to lifestyle modifications. Other side effects and risks may occur.

I agree to inform Practice’s clinical staff of all known factors that might affect treatment, including, but not limited to, all medications, drugs, drug sensitivities and allergies, history of seizures, fits or fainting, presence of a pacemaker, bleeding disorder, use of anti-coagulants, damaged heart valves or occluded vessels, immune deficiencies, or other special risks of infection, as well as any other significant factors within my knowledge. I further agree to inform Practice’s clinical staff of any disorder or state of mind that might affect my capacity to make informed health decisions, and should any such impairment exist, I will provide information regarding a surrogate decision maker.

I understand that Functional Medicine may be different than what some people consider “mainstream” medicine.” I am aware that there is some controversy in the medical community as to integrative or functional medical practices. Some of the potential “risks” of Functional Medicine that are asserted by critics in this debate are:

1. lack of sufficient testing to constitute “evidence-based” medicine;
2. use of biologically active agents that can present risks when used in conjunction with conventional medical therapies;
3. potentially negative biological or psychological effects that have received insufficient testing;
4. delay in seeking mainstream treatment based on scientifically unsupported practices; and
5. use of laboratory tests, the value of which other practitioners question.

I understand that, despite this debate, Provider and/or Practice only employs treatments Provider believes, based on his/her training, experience, evidence-backed studies, and current research, to be safe and effective, and Provider will alert me to the risks and benefits of any treatments before they are administered.

3. Off-Label Use of Devices or Medications. In addition, I understand that Provider may at times use FDA-approved devices or medications to treat a condition in a way that differs from the use specifically approved by the FDA for such device or medication. This is commonly known as “off-label use.” Provider has informed me of this practice and will inform me and provide the opportunity for me to ask questions if Provider decides to use an FDA-approved device or medication off-label in conjunction with my treatment. I am requesting that Provider use his/her judgment in prescribing FDA devices or medications for me that are off-label but which he/she believes to be appropriate.

4. Alternatives and Responsibility to Maintain Separate Primary Care Physician. As alternatives, Provider encourages me to speak with and consider the advice of other Providers, including conventional or mainstream physicians and providers. Provider will consult with, but does not replace, care currently provided to me by other physicians or providers, such as my internist, gynecologist, cardiologist, gastroenterologist, pediatrician (in the case of children), oncologist or other specialty care provider. In addition to discussing other modes of therapy that may be used for the treatment of my condition, Provider and I have discussed, and I understand, the possibility of a referral to a specialist for my condition(s) if I have not already consulted with an appropriate specialist. Provider has advised me that he/she does not admit patients to the hospital or treat hospitalized patients.

I understand that as a condition of my treatment by Practice, I must maintain a relationship with an outside physician to act as my primary care provider and to provide emergency and urgent care. If I encounter a medical emergency and am not able to obtain care from my primary care physician(s), I will contact 911 or report to a hospital emergency department as appropriate.

5. Medication and Responsibilities. I understand that Practice may make available medications, nutritional supplements and other products for sale to patients in its office and on its website. I understand that I am not obligated to purchase these products from Practice, and I can purchase medications, dietary supplements, and other products from any source of my choosing.

I understand that, as with any health treatment, there is no guarantee that I will obtain satisfactory results. If I am being treated for a medical condition, or have symptoms that suggest a medical condition may be present, I have been informed that it is in my best interest to discuss potential alternative methods of treatment for my condition with my primary care physician or an appropriate specialist before, as well as during, the course of treatments. I understand the services provided by Practice do not preclude me from using other treatments as well, though I recognize that I should inform any practitioners I am seeing about the various treatments I am using. I understand that my failure to comply with any treatment recommendations will have an impact on the results of treatment.

I understand that I must immediately inform Practice’s clinical staff of any adverse effect of treatment noted, including any unanticipated pain or other negative sensation, unpleasant cognitive conditions, anxiety, depression or other negative emotions or any unpleasant taste or smell associated with the consumption of supplements or herbs.

I will immediately notify Practice’s clinical staff in the event of pregnancy or breastfeeding, as some treatments may be contraindicated for pregnant or breastfeeding patients.

I understand that I am responsible for disclosing to Provider all medications, care, and assessments that I receive elsewhere and to provide medical records from other providers to ensure that care is coordinated and compatible. Likewise, I am responsible for informing any other health professionals of the treatments, supplements, and/or medications I undergo with Provider and/or Practice.

I understand that Provider’s treatment may include the recommendation that I seek other types of treatment from other health professionals who are not affiliated with Practice. I understand that while Provider may communicate with these professionals to explain why Provider made the recommendation, Provider does not supervise them and is not responsible for them.

I understand that Practice does not accept insurance and I agree that I am financially responsible for the services rendered. I understand that insurance companies are likely to consider Functional Medicine to be non-covered or to deny claims for Functional Medicine as non-standard care, preventative care, or as not medically necessary. I understand that Practice may provide me with a receipt for services called a “superbill.” I understand that I may submit this superbill to my insurance company or any third-party payor, including any government payors, for any services rendered by Practice. I understand that I may not receive full reimbursement or any reimbursement at all from these third-party payors. I also understand that if I am, or during the course of my relationship with Practice, become an eligible Medicare Beneficiary, then I will be given notice of Practice’s status with respect to Medicare and that I will be given separate notice about my financial responsibilities as they relate to Medicare.

NOTE: Do not sign this form unless you have read it and feel that you understand it. Ask any questions you might have before signing this form. Do not sign this form if you have taken medications which may impair your mental abilities or if you feel rushed or under pressure.

By signing below, I acknowledge and certify that I have had opportunities to ask questions and have had them answered to my satisfaction; I have read and fully understand the foregoing Informed Consent, and I have all of the knowledge I currently desire; I have discussed the issues noted above with Provider; and I agree and accept all of the terms above. I am legally competent and have sufficient knowledge to give voluntary and informed consent.

1. Purpose. The purpose of this form is to obtain your consent for the use of telemedicine consultations with Provider. The purpose of the use of telemedicine consultations is to assist in the care and services provided by Practice and ultimately to assist in your care.

2. Nature of Telemedicine Consultation. Telemedicine involves the use of audio, video or other electronic communications to interact with you, consult with your healthcare provider and/or review your medical information for the purpose of diagnosis, therapy, follow-up and/or educational purposes. During your telemedicine consultation, details of your medical history and personal history information may be discussed with other health professionals through the use of interactive video, audio and telecommunications technology. Additionally, a physical examination of you may take place and video, audio, and/or photo recordings may be taken.

3. Risks, Benefits and Alternatives. The benefits of telemedicine include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. Additional benefits are that patients may be diagnosed and treated earlier which can contribute to improved outcomes and less costly treatments. Potential risks of telemedicine include that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment.

Practice has taken the following steps to ensure the privacy of the telemedicine consultation:

• We use only HIPAA compliant software through our Electronic Medical Record (EMR) software, teleconferencing software, and other electronic service providers;
• We have taken steps to encrypt data stored on local devices, if any;
• We use password protected screen savers and data files; and
• We use other reliable authentication techniques and safeguards, both electronically and physically, to reduce the likelihood of patient data or privacy breaches.

In rare instances, technology failure may lead to the loss of information provided through telemedicine consultations. Additionally, in rare instances, security protocols could fail causing a breach of patient privacy. In rare cases, a lack of access to complete and/or accurate medical records or information may result in adverse drug reactions, allergic reactions, or other judgment errors. You agree to hold Provider and Practice harmless from any such information loss, and any resulting judgments or decisions, due to technological failures outside of their agency or control. The quality of transmitted data may also affect the quality of the services provided via the telemedicine consultation. The alternative to telemedicine consultation is a face-to-face visit with a physician.

4. Medical Information and Records. All laws concerning patient access to medical records and copies of medical records apply to telemedicine. Dissemination of any patient identifiable images or information from the telemedicine consultation shall not occur without your consent.

5. Confidentiality. All existing confidentiality protections under federal and state law apply to information used or disclosed during your telemedicine consultation. However, there are both mandatory and permissive exceptions to confidentiality, which may allow or require disclosure of information used or disclosed during the telemedicine consultation. You will be informed of any parties who will be present from the Practice during your telehealth consultation, and will have the opportunity to exclude anyone from attending the consultation.

6. Rights. You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consultation without affecting your right to future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. You have the right to be informed of and object to videotaping or other recording of the telehealth consultation.

By signing below, I acknowledge and certify that:

• I understand that I may expect anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
• I have had opportunities to ask questions and have had them answered to my satisfaction.
• I have read and fully understand the foregoing Telemedicine Consent, and I have all of the knowledge I currently desire.
• I agree and accept all of the terms above. I am legally competent and have sufficient knowledge to give voluntary and informed consent.

NOTE: Do not sign this form unless you have read it and feel that you understand it. Ask any questions you might have before signing this form. Do not sign this form if you have taken medications which may impair your mental abilities or if you feel rushed or under pressure.

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.

Your health information is private, and no one without a legitimate need to know may have access to it. IntegrativeMD (“Practice”) is required by law to maintain the privacy of your health information and to provide you with a notice of its legal duties and privacy practices. In the unlikely event that your health information becomes unsecured, Practice will provide you with prompt notification.

Practice will not use or disclose your health information except as described in this Notice of Privacy Practices (“Notice”). This Notice applies to all of the medical records generated during your treatment at Practice.

EXAMPLES OF DISCLOSURE FOR TREATMENT, PAYMENT AND HEALTH OPERATIONS

The following categories describe the ways that Practice may use and disclose your health information:

Treatment: Practice will use your health information in the provision and coordination of your healthcare. We may disclose all or any portion of your medical record information to your physician, consulting physician(s), nurses and other healthcare providers who have a legitimate need for such information in the care and continued treatment of the patient. For example, a healthcare provider treating you for an injury can ask another healthcare provider about your overall health condition.

Payment: Practice may release medical information about you for the purposes of determining coverage, billing, claims management, medical data processing and reimbursement. The information may be released to an insurance company, third-party payor or other entity (or their authorized representatives) involved in the payment of your medical bill and may include copies or excerpts of your medical record that are necessary for payment of your account. For example, to the extent Practice bills for services it provides to you, a bill sent to a third-party payor may include information that identifies you, your diagnosis, the procedures and supplies used.

Routine Healthcare Operations: Practice may use and disclose your medical information during routine health care operations to run our practice, improve your care, and contact you when necessary. For example, we can use your health information to manage your treatment and services.

Business Associates: Practice may use and disclose certain health information about you to its business associates. A business associate is an individual or entity under contract with Practice to perform or assist Practice in a function or activity that necessitates the use or disclosure of medical information. Examples of business associates include but are not limited to, a copy service used by the Clinic to copy medical records, consultants, independent contractors, accountants, lawyers, medical transcriptionists and third-party billing companies. Practice requires the business associate to protect the confidentiality of your medical information. In addition, Practice requires any subcontractor of Practice’s business associate to protect the confidentiality of your medical information.

Regulatory Agencies: Practice may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability. For example, billing practices may be audited by the State Auditor and records are subject to review by the Secretary of Health and Human Services and his/her authorized representatives.

Workers’ Compensation: Practice may release medical information about you for worker’s compensation or similar programs that provide benefits for work-related injuries or illnesses.

Military Veterans: Practice may disclose your medical information as required by military command authorities if you are a member of the armed forces.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement officer, Practice may release your medical information to the correctional institution or law enforcement official.

Organ and Tissue Donation Requests: Medical information can be shared with organ procurement organizations.

Medical Examiner or Funeral Director: Medical information can be shared with a coroner, medical examiner, or funeral director when an individual dies.

Required by Law: Practice will disclose medical information about you when required to do so by law, for example, responding to lawsuits and legal actions.

Other Uses: Any other uses and disclosures will be made only with your written authorization.

PATIENT INFORMATION RIGHTS

Although all records concerning your treatment obtained at Practice are the property of Practice, you have the following rights concerning your medical information:

Right to Confidential Communications: You have the right to receive confidential communications of your medical information by alternative means or at alternative locations. For example, you may request that Practice contact you only at work or by mail. Right to Inspect and Copy: You have the right to inspect and copy your medical information.

Right to Amend: You have the right to amend your medical information. Any request for amendment should be submitted to Practice in writing, stating a reason in support of the amendment.

Right to an Accounting: You have the right to obtain an accounting of the disclosures of your medical information made during the preceding six (6) year period.

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your medical information. Practice is not required to honor your request except where: (i) the disclosure is for the purpose of carrying out payment or healthcare operations and is not otherwise required by law, and (ii) the medical information pertains solely to a healthcare item or service for which you, or person other than the health plan on your behalf, has paid Practice in full.

Right to Receive a Paper Copy: You have the right to receive a paper copy of this Notice. Right to Receive Electronic Copies: You have the right to receive electronic copies of your medical information.

Right to 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.

Right to Revoke Authorization: You have the right to revoke your authorization to use or disclose your medical information, except to the extent that action has already been taken in reliance on your authorization. A request to exercise any of these rights must be submitted, in writing, to Practice at 128 Prince St #21, Tappahannock, VA 22560, or by contacting Practice at (301) 538-3680.

FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have questions and would like additional information, you may contact our office at (301) 538-3680. If you believe your privacy rights have been violated, you may file a complaint with us by calling (301) 538-3680 and with the U.S. Department of Health and Human Services Office for Civil Rights by calling 1-800-368-1019, visiting https://ocrportal.hhs.gov/ocr/ smartscreen/main.jsf, emailing OCRComplaint@hhs.gov, or sending a letter to:

Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201

We will not retaliate against you for filing a complaint.

CHANGES TO THIS NOTICE

Practice will abide by the terms of the Notice currently in effect. Practice reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. An updated version of the Notice may be obtained at Practice.

RECITALS

WHEREAS, Practice provides functional medical services and delivers personalized care, as enumerated in Attachment A, Fee Schedule, incorporated herein by reference; and

WHEREAS, Patient, according to the terms of this Agreement, desires to contract with Practice to obtain such services and care.

NOW, THEREFORE, in consideration of the foregoing recitals, which are incorporated as covenants, and the mutual promises herein made and exchanged, and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Parties agree as follows:

AGREEMENT

1. Definitions. Throughout this Agreement, the following terms shall have the following meanings:

1. “Practice” shall mean IntegrativeMD, together with any and all of its medical practitioners
2. “Patient” shall mean the individual (or individuals) specifically listed above and documented on the appropriate Client Intake Form(s). If one or more minors, incapacitated persons or persons subject to a power of attorney are documented on the appropriate client intake form(s), “Patient” shall include, jointly and severally, the parent, legal guardian, or surrogate decision maker of the Patient.
3. “Services” shall mean those services specifically enumerated in Attachment A and shall exclude any and all other services not specifically enumerated, including, but not limited to, specialized services, emergency services, prescriptions, supplements, lab work, x-rays, ultrasound, MRI or those services Practice is not equipped, licensed or otherwise capable of providing.

2. Fees. In consideration for the Services provided, Patient agrees to pay Practice the amount(s) as set forth in Attachment A. This fee is due at the time Services are rendered. The Parties agree that the fee payable herein is fair market value for the specific Services rendered. Practice reserves the right to discontinue providing Services to Patient upon Patient’s failure to pay any fees pursuant to this Agreement.

3. Collections Policy. In the event of nonpayment, Practice reserves the right to turn your account over to a collection agency or attorney in order to obtain payment of fees owed.

4. Non-Participation in Insurance. Patient understands and acknowledges that Practice does NOT participate in any private or government funded health insurance, PPO or HMO plans or panels and has opted-out of Medicare. Practice shall not submit bills to any government or private insurer or federal or state health care program (including Medicare, Medicaid, Tri-Care, Veterans Affairs, Federal Employee Health Benefits, etc.) for Services even if deemed to be a covered service under such third-party insurance plan, and acknowledges that neither Practice nor its professionals will bill any third-party health insurance plan for the Services provided to Patient. Patient shall, therefore, remain fully and completely responsible for payment to Practice. Practice does not make any representation or warranty whatsoever that any fees paid under this Agreement are covered by Patient’s health insurance or other third-party payment plans applicable to the Patient. Practice may provide receipts for services known as superbills. Patient may submit such superbills to any government or private insurer or federal or state health care program (including Tri-Care, Veterans Affairs, Federal Employee Health Benefits, etc.) for Services subject to the limitations of the policies and procedures of those third-parties. Patient hereby represents and warrants that Practice has advised Patient to either obtain or keep in full force such health insurance policy(ies) or plan(s) that will cover Patient for general health care costs. Patient acknowledges that this Agreement does not cover hospital services, or any services not personally provided by Practice.

Medicare Beneficiaries: Despite what is written in the paragraph above, if Patient is subject to a Medicare Private Contract with Practice or Advanced Beneficiary Notice provided by Practice, Patient understands that any Medicare Private Contract or Advanced Beneficiary Notice take precedence and Patient agrees to abide by those documents where those documents conflict with this Section 4.

5. Private Contract. If Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, then Patient agrees to sign a Private Contract in the form designated by Practice. To the extent required by law, Patient agrees to enter into a renewed Private Contract every two (2) years, as requested by Practice.

6. Communications. Patient understands and agrees that e-mail communications (outside of the secure patient portal), facsimile, video chat, instant messaging, and cell phone are not guaranteed to be encrypted, secure or confidential methods of communications. Patient agrees that any communications made outside of the patient portal are made at Patient’s risk with respect to all e-mail communications. Patient understands that use of electronic communication outside of the secure patient portal has inherent limitations, including possible breach of privacy or confidentiality, difficulty in validating the identity of the parties, and possible delays in response. Practice will not respond to e-mails or other messages that contain sensitive medical information.

If a response is requested, Practice will respond through the secure patient portal. Though it is Practice’s policy only to respond through the patient portal, by initiating correspondence through an unsecure and/or unencrypted channel, Patient hereby expressly waives Practice’s obligation to guarantee confidentiality with respect to correspondence using such means of communication. Patient understands and acknowledges that Practice may retain any communications between Practice and Patient and include such communications in Patient’s medical record.

Patient understands and agrees that portal messaging or e-mail are not appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation which Patient reasonablybeliev es could develop into an emergency, Patient shall call 911 or proceed to the nearest emergency room, and follow the directions of emergency personnel.

Practice checks telephone and portal messages during business hours and responds to them on a regular basis throughout the week. Portal messages are to be used for non-urgent messages only, and a response will generally be sent within two (2) business days. By leaving a telephone or portal message, Patient acknowledges and agrees that a prompt reply is NOT required or expected and acknowledges that Patient will not use portal messages to deal with emergencies or other time sensitive issues.

Practice expressly disclaims any liability associated with any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient as a result of any action, inaction, technical issues, or activity outside Practice’s control, including but not limited to, (i) technical failures attributable to any Internet service provider, (ii) power outages, failure of any electronic messaging software, or failure to properly address portal messages, (iii) failure of Practice’s computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of e-mail communications by a third-party; or (v) Patient’s failure to comply with the guidelines regarding use of e-mail communications set forth in this Section.

7. Practice is not Primary Care Provider. Practice’s medical practitioners are not Patient’s primary care physicians. Patient is required to have a separate primary care physician on file with Practice. If Patient encounters a medical emergency and is not able to obtain care from Patient’s primary care physician(s), Patient shall contact 911 or report to a hospital emergency department as appropriate.

8. Change of Law. If there is a change of any law, regulation or rule, federal, state or local, (“Applicable Law”) which affects this Agreement, or the duties or obligations of either Party under this Agreement, or any change in the judicial or administrative interpretation of any such Applicable Law, and Patient reasonably believes in good faith that the change will have a substantial adverse effect on his/her rights, obligations or operations associated with this Agreement, then Patient may, upon written notice, require Practice to enter into good faith negotiations to renegotiate the terms of this Agreement. If the Parties are unable to reach an agreement concerning the modification of this Agreement within forty-five (45) days after the date of the effective date of change, then either Party may immediately terminate this Agreement by written notice to the other Party.

9. Severability. If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of this Agreement shall not be affected. Any invalid or unenforceable provision shall be modified to the minimum extent necessary so as to remove the basis for invalidity or unenforceability.

10. Amendment. No amendment of this Agreement shall be binding on Practice unless it is made in writing and signed by Practice. Practice may unilaterally amend this Agreement, to the extent permitted by Applicable Law, by sending Patient a thirty (30) day advance written notice of any such change. Any such changes are hereby incorporated by reference into this Agreement without the need for signature of Patient and are effective as of the date established by Practice, except that Patient shall initial any such change upon Practice’s request. Moreover, if Applicable Law requires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been expressly set forth in this Agreement.

11. Assignment. This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient. Practice may assign this Agreement in whole or in part provided Practice provides Patient with written notice of such assignment. To the extent Practice assigns this Agreement in whole or in part, the transferee or assignee shall enjoy and undertake the same rights and obligations herein as Practice has hereunder to the extent incorporated in such assignment.

12. Relationship of Parties. Patient and Practice intend and agree that Practice, in performing Services pursuant to this Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and the United States Department of Labor, and Practice shall have complete control over the manner in which the Services are performed.

13. Legal Significance. Patient understands and acknowledges that this Agreement is a legal document that creates certain rights and responsibilities. Patient represents and warrants that he/she has had reasonable time to seek legal advice regarding this Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of this Agreement.

14. Force Majeure. Neither Party shall be liable to the other for the failure or delay in the performance of any of the obligations under this Agreement when such failure or delay is due, directly or indirectly, to any act of God, acts of civil or military authority, acts of public enemy, terrorism, fire, flood, strike, riots, wars, embargoes, governmental laws, orders or regulations, storms or other similar or different contingencies beyond the reasonable control of the respective Parties.

15. Miscellaneous. This Agreement shall be construed without regard to any presumptions or rules requiring construction against the Party causing the instrument to be drafted. Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text.

16. Entire Agreement. This Agreement contains the entire agreement between the Parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement.

17. Notice. All written notices are deemed received by Practice if sent to the address of Practice written above and by Patient if sent to the Patient’s address appearing in the applicable client intake form(s), provided notice to either Party is sent by Certified U.S. Mail, Return Receipt Requested. If Patient changes his/her address, Patient shall notify Practice promptly of his/her change of address.

18. Governing Law; Venue; Waiver of Jury Trial. Any controversy or claim arising out of or relating to this Agreement, or the breach thereof, shall be settled by binding arbitration. The demand for arbitration shall be made within a reasonable time after the claim, dispute or other matter in question has arisen, and in no event shall it be made more than two (2) years from when the aggrieved Party knew or should have known of the controversy, claim or dispute. The number of arbitrators shall be one. If the Parties are unable to agree upon the selection of an arbitrator within twenty-one (21) days of commencement of the arbitration proceeding by service of a demand for arbitration, the arbitrator shall be selected by the American Arbitration Association. The place of arbitration shall be Essex County, VA and Virginia law shall apply. Judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. Each Party shall pay its own proportionate share of arbitrator fees and expenses.

BOTH PARTIES EACH IRREVOCABLY WAIVE THE RIGHT TO A JURY TRIAL IN CONNECTION WITH ANY LEGAL PROCEEDING RELATING TO THIS AGREEMENT

IN WITNESS WHEREOF, the Parties hereto have executed this Agreement on the Effective Date.

WHEREAS, IntegrativeMD (“Practice”) provides functional medical services and delivers personalized care; and

WHEREAS, Patient, desires to contract with Practice to obtain such services and care.

NOW, THEREFORE, Patient agrees to abide by the following business policies:

1. Initial Consult Time Limitations. Prior to the Initial Consult, Patient must fill out the medical history questionnaire and complete bloodwork at a lab. Because the lab results lose accuracy over time, Patient must schedule the Initial Consult within ninety (90) days of the blood draw at the lab. If Patient fails to do so, Patent may be asked to complete the blood work again. Practice will make reasonable efforts to contact Patient to schedule the Initial Consult once Practice receives the results from the lab.

2. Appointment Cancellation Policy. If for any reason Patient must cancel a scheduled Initial Consult appointment (whether with Dr. John Chiles, M.D. or with any other provider, including health coaches or dietitians), Patient shall give Practice written notice at least twelve (12) hours before the appointment time. If Patient fails to give sufficient twelve hours notice, then the Initial Consult appointment is forfeited and will need to be rescheduled at Dr. John Chiles availability, and a $25 fee will be assessed to the patient for the late cancellation.

3. No Refunds. Practice does NOT offer refunds for the Initial Consult.

4. Offer to Move Forward with Practice. Practice is a fee for service functional medicine practice. After the Initial Consultation, Dr. John Chiles, M.D. or another Practice provider may decide, based on the Patient’s case, to offer Patient the opportunity to join Practices’s fee for service for continued care as a patient.

5. Responsibility to Maintain Separate Primary Care Physician. Practice medical providers may consult with, but do not replace, care currently provided to Patient by other physicians, such as an internist, gynecologist, cardiologist, gastroenterologist, pediatrician (in the case of children), oncologist or other specialty care provider. Patient understands the possibility of a referral to a specialist for my condition(s) if Patient has not already consulted with an appropriate specialist. Practice medical providers, including Dr. John Chiles, M.D., do not admit patients to the hospital or treat hospitalized patients.

Dr. John Chiles, M.D. does not function as a primary care provider. Rather, Practice acts as an extension of Patient’s medical team in working on root cause resolution. As a condition of receiving services from Practice, Patient must maintain a relationship with an outside physician to act as a primary care provider and to provide emergency and urgent care. If Patient encounters a medical emergency and is not able to obtain care from his or her primary care physician(s), Patient is advised to contact 911 or report to a hospital emergency department as appropriate.

6. Non-Participation in Insurance. Patient understands and acknowledges that Practice does NOT participate in any private or government funded health insurance, PPO or HMO plans or panels and has opted-out of Medicare. Patient shall not submit bills to any federal or state government payor (including Medicare, Medicaid, Tri-Care, Veterans Affairs, Federal Employee Health Benefits, etc.) for Services even if deemed to be a covered service under such insurance or health care plan. Patient acknowledges that neither Practice nor its professionals, including Dr. John Chiles, M.D., will bill any third-party health insurance plan for the Services provided to Patient.

However, Patient may, at Patient’s discretion, independently submit bills only to Patient’s private insurance company. However, Practice does not make any representation or warranty whatsoever that any fees paid under this Agreement are covered by Patient’s health insurance plan. Patient shall be fully and completely responsible for payment to Practice. Patient is hereby advised to either obtain or keep in full force such health insurance policy(ies) or plan(s) that will cover Patient for general health care costs. Patient acknowledges that any health care agreements made with Practice do not cover hospital services, or any services not personally provided by Practice.

7. Post-Initial Consult Communications. Practice will not provide continued care in terms of portal messaging support, phone calls or visits after the Initial Consult unless Patient enters into a membership agreement to continue care with Practice. However, Practice providers or staff will substantively respond and answer inquiries seeking to clarify the recommendations made at the Initial Consult or to answer supplement usage or dosage questions. If, in the sole discretion of Practice, Patient’s questions exceed the scope of that limited exception, Patient will be encouraged to come in for an appointment, and thus begin membership with Practice, or to seek counsel from their primary care physician.

8. General Communications Policy. Patient understands and agrees that e-mail communications (outside of the secure patient portal), facsimile, video chat, instant messaging, and cell phone are not guaranteed to be encrypted, secure or confidential methods of communications. Patient agrees that any communications made outside of the patient portal are made at Patient’s risk with respect to all e-mail communications. Patient understands that use of electronic communication outside of the secure patient portal has inherent limitations, including possible breach of privacy or confidentiality, difficulty in validating the identity of the parties, and possible delays in response. 

Practice will not respond to e-mails or other messages that contain sensitive medical information. If a response is requested, Practice will respond through the secure patient portal. Though it is Practice’s policy only to respond through the patient portal, by initiating correspondence through an unsecure and/or unencrypted channel, Patient hereby expressly waives Practice’s obligation to guarantee confidentiality with respect to correspondence using such means of communication. Patient understands and acknowledges that Practice may retain any communications between Practice and Patient and include such communications in Patient’s medical record.

Patient understands and agrees that portal messaging or e-mail are not appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation that Patient reasonably believes could develop into an emergency, Patient shall call 911 or proceed to the nearest emergency room, and follow the directions of emergency personnel.

Practice checks telephone and portal messages during business hours and responds to them on a regular basis throughout the week. Portal messages are to be used for non-urgent messages only, and a response will generally be sent within two (2) business days. By leaving a telephone or portal message, Patient acknowledges and agrees that a prompt reply is NOT required or expected and acknowledges that Patient will not use portal messages to deal with emergencies or other time sensitive issues.

Practice expressly disclaims any liability associated with any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient as a result of any action, inaction, technical issues, or activity outside Practice’s control, including but not limited to, (i) technical failures attributable to any Internet service provider, (ii) power outages, failure of any electronic messaging software, or failure to properly address portal messages, (iii) failure of Practice’s computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of e-mail communications by a third-party; or (v) Patient’s failure to comply with the guidelines regarding use of e-mail communications set forth in this Section.