1. Administrative Facility Fee
I understand and agree that AceMed Seattle, PLLC will charge a monthly administrative facility fee of $35.00 beginning September 1, 2025. This fee will be automatically charged on the numerical date chosen below each month to the payment method I have on file with the practice.

2. Purpose of Fee
I understand that this fee helps cover administrative and operational costs including but not limited to: Enhanced patient communication and portal management Dedicated administrative staffing Facility maintenance and improvements Administrative services not covered by insurance Electronic health record maintenance and security

3. Payment Terms
The fee will be charged monthly regardless of whether I have appointments scheduled that month The fee is separate from and in addition to any copays, deductibles, or other charges related to medical services The fee is separate from, and in addition to, charges for medical services, procedures, or other care. The fee is due and payable even if I have an outstanding balance for medical services This fee is non-refundable once charged

4. Insurance Coverage
I understand that: This administrative fee is NOT covered by insurance and is the sole responsibility of the patient This fee cannot be submitted to insurance for reimbursement This fee may not qualify for HSA/FSA reimbursement This fee is not a direct medical expense and is may not be tax-deductible I acknowledge and agree with the purpose and necessity of the administrative facility fee

5. Card on File Authorization
I authorize AceMed Seattle, PLLC to: Keep my credit/debit card information securely on file Charge the monthly administrative fee to this card on a recurring basis Update my card information as needed to ensure continuous service

6. Termination
I may terminate this agreement at any time by providing written notice to AceMed Seattle, PLLC Termination will be effective at the end of the current billing cycle Upon termination, I understand that I may no longer be accepted as a patient at AceMed Seattle, PLLC Re-enrollment may be subject to availability and practice discretion

7. Fee Changes
I understand that AceMed Seattle, PLLC reserves the right to adjust the administrative fee amount with 30 days' written notice that may be delivered electronically through the email address on file.

8. Financial Hardship I understand that if I experience financial hardship, I may contact the practice to discuss possible temporary arrangements. Any special arrangements must be documented in writing.

9. Release and Hold Harmless
I agree to release and hold harmless AceMed Seattle, PLLC, its physicians, employees, associates, affiliates, and agents from any claims, demands, or causes of action related to the implementation and collection of this administrative facility fee, provided that such fee is collected in accordance with this agreement.

10. Dispute Resolution
Any disputes arising from this agreement shall first be addressed through good faith discussions between the patient and practice administration. If resolution cannot be reached, disputes shall be resolved through binding arbitration in accordance with the rules of the American Arbitration Association.

11. Entire Agreement
This agreement constitutes the entire agreement between the parties regarding the monthly administrative facility fee and supersedes any prior understandings or agreements, whether written or oral.

By signing below, I acknowledge that:

• I have read and understood all terms of this agreement
• I have had the opportunity to ask questions about the fee and this agreement
• I voluntarily consent to the monthly administrative facility fee under no duress or obligation
• I will have the opportunity to receive a copy of this agreement for my records

For Patients Using Insurance

I understand that this fee is separate from and does not affect my insurance coverage for medical services. I will continue to be responsible for all copays, deductibles, and non-covered medical services as determined by my insurance plan.