Welcome to Alexander Medical. Please review this agreement carefully, as it outlines the policies, expectations, and responsibilities that guide your care. Your initials and signature are required in order to proceed with treatment.

At Alexander Medical, we provide a unique style of care that combines concierge primary care services with an emphasis on hormone optimization, lifestyle medicine, and preventive health. We are a concierge clinic, which means we do not bill or accept insurance. Instead, we focus on delivering personalized, evidence-based care without the limitations of insurance-driven models.

Our approach includes:

• Hormone Therapy: We use hormone medicines when appropriate, including off-label applications, in ways supported by clinical research and evidence-based guidelines to ensure both safety and effectiveness.
• Lifestyle Focus: We prioritize nutrition, exercise, sleep, stress management, and overall wellness, often using these as first-line strategies before turning to medications.
• Primary Care Services: In addition to hormone therapy and wellness care, we provide comprehensive primary care to address your broader health needs.
   

This agreement reflects our commitment to providing transparent, patient-centered care while also ensuring that clinic policies are clear and consistently applied.

ELECTRONIC COMMUNICATION AGREEMENT

Alexander Medical offers the option to communicate with our office staff and providers through email, text (SMS) messaging, and voicemail for your convenience. Before electing to use these forms of communication, please review the following important information.

Purpose of Electronic Communication

• Text messaging (SMS) may be used for appointment reminders, scheduling updates, billing notices, prescription notifications, and limited clinical follow-up questions.
• Email may be used to send relevant clinical information such as lab results, result interpretations, and follow-up instructions.
• Voicemail messages may be left regarding scheduling, clinical information, or follow-up care.
• These communication methods are not appropriate for emergencies, urgent medical concerns, or sensitive clinical discussions.

Risks and Limitations

While Alexander Medical takes precautions to safeguard your health information, it is important to understand the following:

• Confidentiality: Standard text messaging and personal email accounts are not encrypted and may be accessed by unauthorized individuals (for example, if your phone is lost, stolen, or viewed by others).
• Reliability: Text and email messages may be delayed, misdirected, or not delivered.
• Documentation: Electronic communications may become part of your medical record.
• Content Restrictions: Sensitive health information, diagnostic results, detailed clinical discussions, or complex care instructions should be handled via secure communication methods, phone calls, or office visits.

Patient Responsibilities

• Keep your email address and mobile phone number current with our office.
  Protect your devices with a password or lock screen to help safeguard your health information.
• Do not use text or email for emergencies. If you are experiencing a medical emergency, call 911.
• Understand that messages may not be read immediately. Please allow up to one business day for responses.
   

Consent and Acknowledgment

By initialing below, you acknowledge and agree to the following:

1. I understand that email and text messaging are not fully secure forms of communication and may carry a risk of unauthorized access, as described above.
2. I authorize Alexander Medical to send me text messages, emails, and voicemail communications related to scheduling, reminders, billing, lab results, and limited clinical matters.
3. I understand that I may withdraw my consent to receive electronic communications at any time by notifying Alexander Medical in writing.
4. I agree not to use email or text messaging for urgent issues, emergencies, or sensitive medical information. 

USE OF AI SCRIBE TECHNOLOGY

At Alexander Medical, we are committed to providing the highest level of personalized care. To help us stay focused on you rather than our computer screens, we may use secure AI scribe technology during your visits.

This means that portions of your visit may be audio recorded and transcribed to create accurate medical documentation. These tools allow us to capture important details while giving you our full attention, ensuring that nothing is missed and that your care is documented with precision.

All recordings are handled in accordance with strict privacy and security standards, and are used solely for the purpose of enhancing your medical record and the quality of your care.

By using this technology, we aim to spend more time listening to you, and less time typing, so that every visit is focused on your health and well-being.  

Patient Acknowledgment:

By initialing below, you acknowledge and accept that portions of your visit may be audio recorded and transcribed for medical documentation purposes as outlined above.

HIPAA – NOTICE OF PRIVACY PRACTICES

Alexander Medical is required by law to maintain the privacy and confidentiality of your protected health information (PHI). This Notice of Privacy Practices explains our legal duties, how we may use or disclose your information, and your rights regarding that information.

How We May Use or Disclose Your Health Information

We may use or share your health information in order to:

• Plan and provide your care and treatment
• Coordinate or provide treatment by us or other providers (including referring physicians)
• Communicate with other healthcare professionals involved in your care
• Receive payment from you, your health plan, or your insurer
• Conduct healthcare operations such as quality assessments and outcome improvements
• Inform you of services and treatments that may benefit you;
  Comply with federal and state laws that require disclosure of health information

We may also disclose your health information as necessary in certain situations, such as:

• Workers’ Compensation cases
• Public health activities
• Emergencies
• Judicial or administrative proceedings
• Law enforcement investigations
• Medical examiner or coroner requests
• Approved research studies
• When needed to prevent or reduce a serious threat to health or safety
• Military, national security, or government purposes
• Company-approved marketing or referral acknowledgment
• Change of ownership of the practice

Your Rights Regarding Health Information

You have the right to:

• Review and request corrections to your health record
• Request confidential communications and place limits on disclosures of your health information
• Request an accounting of certain disclosures of your information
• Receive a copy of this Notice and any updates
• Be notified if we cannot agree to a requested restriction
• Request reasonable accommodations for communication by alternative means or locations
   

Our Responsibilities

We are required to:

• Maintain the privacy of your protected health information;
• Provide you with this Notice describing our legal duties and practices;
• Abide by the terms of the most current Notice of Privacy Practices;
• Notify you if we cannot agree to a requested restriction;
• Accommodate reasonable requests for alternative communication.
   

Patient Acknowledgment

I acknowledge that I have received and reviewed the Notice of Privacy Practices from Alexander Medical. I understand my rights, the ways my health information may be used or disclosed, and my ability to request restrictions.

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

At times, you may want a trusted family member, caregiver, or other individual to be involved in your medical care or to have access to your health information. This authorization allows Alexander Medical to share your protected health information with the individual(s) you choose. 

Authorization:

I hereby authorize Alexander Medical to release my protected health information to the following individual(s):

 Patient Rights

• I understand that I have the right to revoke this authorization at any time in writing.
• I understand that revocation will not affect any disclosures made prior to receipt of the revocation.
• I understand that information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by HIPAA.
• I understand that I am not required to sign this form to receive treatment.

By initialing below, I authorize Alexander Medical to release my protected health information as outlined above to the individual(s) listed. 

LABORATORY PROCEDURES CONSENT

PLEASE READ CAREFULLY- THIS MAY AFFECT CHARGES BILLED TO YOU

Patients who elect to use their insurance for Laboratory tests need to be made aware that we do not have any knowledge about what your financial responsibility through your insurance will be. We order labs to monitor and coordinate your care, and these labs are sent to outside laboratory providers. We do not have any information about your insurance regarding their COVERAGE for the particular lab tests, or who your PREFERRED laboratory provider is. The following is a list of common occurrences regarding laboratory testing and payment of such services, and is designed to give you information prior to ordering and incurrence of charges for laboratory tests.

I have read and understand the following information:

1. Our office orders the test(s) we believe to be medically necessary for you. We have NO INVOLVEMENT in the charges for those tests, the billing of those tests, or the insurance company’s payment or non-payment of those tests. These issues are between you the patient, your insurance carrier, and the laboratory used. If clarification of the indication for the test or coding from our office are required, we will provide additional information to the lab.
2. We are not advised by your insurance companies when changes occur to the preferred laboratory providers. The use of a non-preferred laboratory can make the cost to you rise for a given lab test, up to and including the total cost of the lab test(s). We do not have access to information regarding what is a covered or noncovered test.
3. Laboratory testing is often very expensive. We have nothing to do with the fees that the laboratories charge once the lab test is ordered. This is between you, your insurance carrier and the laboratory providing the services. It has been our experience recently, that patient’s are getting lab bills greater then anticipated, and these are greater then the charges incurred at our cash rate. Once the Lab Provider bills the insurance for the labs, WE ARE UNABLE TO CHANGE THIS TO OUR CASH RATE.

You will need to contact your insurance and identify who the preferred lab company is to minimize your costs associated with the laboratory testing.

Patient Acknowledgment:

By initialing below, you acknowledge that you are aware that you are using your insurance to obtain labs, as we have no control over what the lab company charges, and we are unable to switch these charges to an account bill once your insurance has been utilized.

ELECTRONIC FUNDS TRANSFER (EFT) AGREEMENT

Alexander Medical uses electronic funds transfer (EFT) for monthly billing. By initialing below, you authorize the following:

• Monthly Deduction: $100 will be deducted from your designated account or card every month.
• Initial Term: This agreement is for a 12-month duration. After the initial term, payments will automatically continue on a month-to-month basis until you choose to cancel.
• Secure Payment Setup: You will receive a secured billing link to enter your card information. Please notify us once your card has been entered so we can complete your account setup.

Cancellation Policy:

• You may cancel only after at least 4 months from the start of this agreement.
• Written cancellation notice must be sent to Melissa@AlexanderMedCenter.com.
• All cancellation requests must be submitted at least 30 days before the desired stop date.
   

Declined Payments & Secondary Card Authorization:

• If the primary payment method is declined, a secondary payment method (if you have chosen to keep one securely on file) may be charged.
• A $25 fee may be applied for each missed or declined payment.
   

By initialing below, you acknowledge and accept responsibility for these monthly payments until proper cancellation notice is received. You also authorize Alexander Medical to draft your payment on the (day of the month) you have selected.

PATIENT CONDUCT POLICY

At Alexander Medical, we are committed to providing a respectful and safe environment for all patients, providers, and staff. To maintain this environment:

• All patients are expected to treat providers, staff, and fellow patients with courtesy, dignity, and respect at all times.
• Abusive, disruptive, hostile, threatening, or harassing behavior, whether verbal, physical, or written (including electronic communications), will not be tolerated under any circumstances.
• Failure to comply with clinic policies, repeated missed appointments, non-payment of fees, or refusal to follow medically appropriate treatment recommendations may result in dismissal from the practice. 
• Alexander Medical reserves the sole right to limit, suspend, or terminate the care relationship if continued treatment is deemed unsafe, inappropriate, disruptive, or inconsistent with the standards of care.

By initialing below, you acknowledge and agree to abide by this policy, and you understand that violation of these terms may result in termination of services.

ACKNOWLEDGMENT

I have read (or had read to me) this entire agreement. I have had the opportunity to ask questions and all questions have been answered to my satisfaction. I acknowledge that I have read, understood, and agreed to all sections of this Comprehensive Patient Care Agreement. I understand my responsibilities as a patient, my rights regarding my health information, as well as the financial, communication, and patient conduct policies of Alexander Medical.

A copy of this entire agreement can be provided electronically or printed if requested.