Protocol Agreement + Intake Form: Concierge Care Recommended Trial

Protocol Agreement and Intake Form
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Terms and Conditions: Protocol 6-Month Trial Membership

The Program

This Protocol Trial Membership (the “Program”) provides access to select non-clinical services offered by Healthspan Group LLC, d/b/a Protocol (“Protocol”) as described in Exhibit A (“Services”). Protocol offers health education, wellness coaching, and lifestyle guidance. No clinical or medical services are included, and Protocol does not diagnose, treat, or manage any medical conditions.

Trial Membership Fee and Term

Members agree to pay a one-time fee of $2,500 per person for a six (6) month trial membership to access the Services (“Trial Membership Fee”). This Agreement begins on the Effective Date and automatically terminates six (6) months later. There is no automatic renewal.

Renewal

At the end of the six-month term, Members may be offered the opportunity to continue their participation under a new membership agreement at the then-current rates. Continued access to Services is not guaranteed unless a new agreement is signed and payment is received.

Payment Terms

The Trial Membership Fee must be paid in full at the time of enrollment. Payment may be made by the Member or a third party designated by the Member. Unless otherwise noted, the payment method provided at sign-up will be used to process payment through Protocol’s third-party payment processor.

Cancellation and Refunds

Members may cancel their participation at any time during the six-month term; however, the Trial Membership Fee is non-refundable under all circumstances once payment has been processed. No partial refunds will be issued for early cancellation or non-use of services.

Acknowledgment

By enrolling in the Program, the Member acknowledges and agrees to these terms, including that the Program does not include any clinical services and that the Trial Membership Fee is non-refundable.
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As a physician-referred member, you receive expedited onboarding to help you get started as quickly as possible.

On the next page you will be asked to sign a records release form that will allow us to communicate directly with your physician practice for continuity of care.
As physician-referred members, you receive expedited onboarding to help you get started as quickly as possible.

Each member must provide individual consent for the release of health information. On the next page, you’ll be asked to sign a records release form that allows us to communicate directly with your physician practice for continuity of care. Once this form is completed, the other member in your party will receive a separate email requesting their signature as well.

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MEMBER CONSENT FOR DISCLOSURE OF HEALTH INFORMATION

BY SIGNING YOUR NAME BELOW, YOU AUTHORIZE:

(i) PRACTICE AND/OR ITS PHYSICIANS, STAFF, EMPLOYEES, AGENTS AND REPRESENTATIVES, TO SHARE YOUR CONFIDENTIAL PROTECTED HEALTH INFORMATION WITH PROTOCOL, OTHER TREATING PHYSICIANS, HOSPITALS, HEALTH CARE FACILITIES, AND LICENSED HEALTH CARE PRACTITIONERS FOR THE PURPOSE OF PROVIDING SERVICES UNDER THE AGREEMENT.

(ii) PRACTICE AND OR ITS PHYSICIANS, STAFF, EMPLOYEES, AGENTS AND REPRESENTATIVES, TO RELEASE ANY MENTAL HEALTH, SUBSTANCE ABUSE AND HIV/AIDS INFORMATION CONTAINED IN YOUR PROTECTED HEALTH INFORMATION, BUT ONLY IF PRACTICE FIRST OBTAINS YOUR SEPARATE, WRITTEN CONSENT TO DO SO. ADDITIONALLY, AFTER RECEIVING YOUR CONSENT TO DO SO, PRACTICE SHALL ONLY RELEASE SUCH MENTAL HEALTH, SUBSTANCE ABUSE AND HIV/AIDS INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS PURPOSES.

(iii) PRACTICE, PROTOCOL, AND/OR THEIR PHYSICIANS, STAFF, EMPLOYEES, AGENTS AND REPRESENTATIVES, TO SEND YOUR PROTECTED HEALTH INFORMATION TO YOU VIA E-MAIL TO THE E-MAIL ADDRESS LISTED BELOW UPON YOUR REQUEST. ALTHOUGH PRACTICE AND PROTOCOL WILL TAKE STEPS TO KEEP YOUR COMMUNICATIONS CONFIDENTIAL AND SECURE, THE CONFIDENTIALITY OF E-MAIL COMMUNICATION CANNOT BE ASSURED OR GUARANTEED.

(iv) PRACTICE AND PROTOCOL AND/OR THEIR PHYSICIANS, STAFF, EMPLOYEES, AGENTS AND REPRESENTATIVES, TO CONTACT YOU FOR MARKETING PURPOSES WITH RESPECT TO NEW PRODUCTS OR SERVICES OFFERED BY PRACTICE AND/OR PROTOCOL.

PRACTICE’S POLICIES AND PRACTICES GOVERNING ITS USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION ARE AVAILABLE TO YOU UPON REQUEST, AND SUCH POLICIES AND PRACTICES MAY BE CHANGED AS NECESSARY BY PRACTICE AS CONTAINED THEREIN. YOU MAY REQUEST THAT PRACTICE RESTRICT THE USE OR DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION TO ONLY TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS PURPOSES. YOU MAY REVOKE THIS CONSENT AT ANY TIME BY PROVIDING WRITTEN NOTICE TO PRACTICE IN ACCORDANCE WITH THIS AGREEMENT. HOWEVER, IF PRACTICE HAS TAKEN ANY ACTION IN RELIANCE ON YOUR PREVIOUSLY UNREVOKED CONSENT YOUR REVOCATION OF THIS CONSENT SHALL NOT APPLY TO SUCH PREVIOUS ACTIONS TAKEN BY PRACTICE.
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Protocol Agreement and Intake Form