SFM FM Program HSA Addendum

FM Program Agreement, HSA Addendum

Effective February 20, 2023
This HSA Addendum (“Addendum”) outlines modifications to the terms and conditions for the FM Program Agreement executed between the undersigned, (“Patient”) and Sparks Family Medicine, Ltd (“Practice”). The Patient should review the information in this Addendum, including their rights and responsibilities, and retain a copy for future reference.

1.     Required Payment

1.1. Patient has executed the FM Program Agreement with Practice including Attachment A with Functional Medicine Energy Center (“FMEC”) for access to the FMEC Platform.

1.2. FMEC is not a healthcare provider and cannot process Health Savings Account ("HSA") payments.

1.3. Patient desires to utilize an HSA payment method for payment required by the FM Program Agreement.

2.     HSA Coverage

2.1. Practice’s Functional Medicine Program provides access to integrative and functional medicine not covered by health insurance, including the FMEC Platform.

2.2. Practice makes no representations or determinations that the costs for Practice’s services or the costs to access the FMEC Platform are approved HSA expenses.

2.3. Patient should consult with their HSA administrator with any questions regarding approved HSA expenses.

3.     Modification of Payment and Agreement

3.1. Patient requests that Practice processes the required FMEC Platform payment on behalf of FMEC.

3.2. Patient consents to Practice collecting the FMEC Platform payment and making recurring charges consistent with the FM Program Agreement and Attachment A.

3.3. Patient will not receive FMEC Platform emails, including notices of upcoming charges, notices of charges and receipts for charges.

3.4. Patient will not be able to cancel their FM Platform access through the FM Platform, but will instead need to notify Practice in writing consistent with Section 4 of the FM Program Agreement.

4.     All other terms, conditions and responsibilities of the FM Program Agreement and Attachment A are unaffected by this Addendum.
Date*

MonthDayYear
Date
Patient Name*

First NameMiddle Name/InitialLast Name
Patient Date of Birth*

MonthDayYear
Date
Responsible Party (if not the patient)

First NameMiddle Name/InitialLast Name
Relationship to Patient
Email*
example@example.com
Authorization to Receive Password Protected Attachment*

I understand I will receive an email response at the provided email from Sparks Family Medicine, Ltd upon submission of this document with a PDF of the completed agreement attachment. I must use the password Patient#1 to open and save this attachment.
Electronic Signature Acknowledgement and Consent*

I understand and agree that this electronic signature is the legal equivalent of my signature in writing and I consent to be legally bound to this agreement.
Patient/Responsible Party Signature*

Clear
Should be Empty:

FM Program Agreement, HSA Addendum