Endocrinology · Obesity Medicine · Metabolic Health
www.ncendocrinology.com

This Virtual Endocrinology Visit Agreement ("Agreement") is between North County Endocrinology Associates, a California Professional Corporation ("Practice"), and the patient named above ("Patient"). It establishes the terms under which the Practice provides physician-led endocrinology care on a per-visit, cash-pay basis, delivered via telehealth within California.

This Agreement covers the professional services of the physician for the visit(s) the Patient books. It is NOT insurance, is NOT a membership, and does NOT cover the cost of medications, laboratory testing, or imaging.

Care is provided on a per-visit basis. Each visit the Patient books, and reasonable communication directly related to that visit, includes the following physician-led services, delivered by telehealth:

• A new-patient consultation — a 60-minute video visit with Dr. Alkhaddo to review your history, establish care, and develop your treatment plan
• Follow-up visits — focused video visits to review progress and adjust your plan, scheduled as you and the physician determine
• Prescriptions and prior-authorization submission arising from your visit, sent to your pharmacy
• Ordering of laboratory testing or imaging indicated by your visit, sent to your usual laboratory or facility (billed separately — see Section 4)
• An itemized superbill after each visit, on request, that you may submit to your insurer (see Section 4)

Per-visit care does NOT include ongoing between-visit messaging, continuous monitoring, or unlimited physician access. Patients who want ongoing, between-visit support with included follow-up visits and secure messaging may enroll in NCEA Direct Membership instead.

Care is delivered entirely by telehealth. Each visit is a separate engagement to address the matters raised in that visit. There is no ongoing retainer or recurring relationship beyond the visits the Patient books. Additional visits are scheduled when the Patient and physician determine they are appropriate.

Confidential · North County Endocrinology Associates · www.ncendocrinology.com

Medications and treatments are provided only when clinically appropriate based on the physician's independent medical judgment. Booking a visit does not guarantee that any medication will be prescribed, approved by insurance, or produce any particular result. Individual results vary.

The Practice's professional fees for virtual visits are:

The Practice's professional fees for virtual visits are:

Service	Fee
New-patient consultation (60 minutes)	$349
Follow-up visit	$174

Fees are due at the time the visit is booked or at the time of service, as directed by the Practice, and are payable by the Patient. These fees cover the physician's professional services only and do not include the separate costs described in Section 4.3.

The Practice's professional services are cash-pay. The Practice does NOT bill insurance for its professional services. Upon request, the Practice will provide the Patient an itemized superbill that the Patient may submit to their insurer for possible out-of-network reimbursement or credit toward a deductible. Whether any amount is reimbursed is determined solely by the Patient's insurer, and the Practice does not guarantee any reimbursement.

The following are NOT included in the visit fee and are billed separately:

• Medications — sent to the Patient's pharmacy and covered by the Patient's insurance or paid by the Patient
• Laboratory testing and imaging — ordered to the Patient's usual laboratory or facility and billed to the Patient's insurance, as with any physician's order
• Administrative services — completion of disability, FMLA, work, school, or travel forms; letters and detailed written reports; medical-records requests; and similar administrative services, at the Practice's then-current rates

Where a visit results in a prescription that requires prior authorization, the Practice will submit the request to the Patient's insurance. If coverage is approved, the Patient is responsible for any applicable copay; if coverage is denied, the Practice will discuss alternatives. The Practice does not guarantee insurance approval or any particular cost.

Please cancel or reschedule at least 24 hours before a scheduled visit. Visits cancelled with less than 24 hours' notice, or missed without notice, may be charged the full visit fee.

Confidential - North County Endocrinology Associates - www.ncendocrinology.com

These cash-pay services are available only to patients who are NOT beneficiaries of Medicare or Medicaid (Medi-Cal). By signing this Agreement, the Patient attests that:

• The Patient is NOT enrolled in Medicare (Part A or Part B) or Medicaid / Medi-Cal; and
• The Patient will promptly notify the Practice if the Patient becomes enrolled in Medicare or Medicaid at any time while receiving care from the Practice.

If the Patient is, or becomes, a Medicare or Medicaid beneficiary, the Patient is not eligible for these cash-pay services and the Practice cannot continue to provide them on this basis. The Patient understands this eligibility requirement exists because the Practice remains enrolled in Medicare for other services and cannot privately contract on a cash basis for Medicare-covered services with a Medicare beneficiary.

• Provide accurate, complete medical history and disclose all medications and conditions
• Pay the applicable visit fee as described in Section 4
• Attend scheduled video visits, and cancel or reschedule with at least 24 hours' notice
• Use the HIPAA-compliant secure messaging platform for any clinical communication related to a visit
• Report side effects, adverse reactions, or concerning symptoms promptly
• Complete recommended laboratory monitoring as directed
• Maintain an established primary care provider for general medical care
• Not rely on these services for emergency care — call 911 in an emergency
• Promptly notify the Practice of any change in Medicare or Medicaid enrollment (Section 5)

This Agreement governs each cash-pay visit the Patient books with the Practice and remains in effect for successive visits unless terminated by either party. It creates no membership, no recurring charge, and no obligation on either party to schedule future visits. The Practice may decline to provide a service or prescription where clinically inappropriate, and either party may discontinue the care relationship at any time, consistent with the physician's obligation not to abandon a patient and to provide reasonable notice.

Per-visit care is centered on the scheduled video visit. Brief communication through the Practice's secure messaging platform directly related to a recent visit may be included at the physician's discretion. Per-visit care does not include ongoing between-visit management, continuous monitoring, or unlimited messaging. A new problem, or a concern that requires an examination or more detailed clinical decision-making, will be addressed in a scheduled visit, consistent with the standard of care. These services are not a substitute for primary care or for urgent or emergency services. For a medical emergency, call 911.

These services are NOT health insurance and do not satisfy any requirement to maintain health insurance. The Patient should maintain comprehensive health insurance independently.

Confidential • North County Endocrinology Associates • www.ncendocrinology.com

Visit fees are payment for the physician's professional services at each visit and are not prepaid medical care for items billed separately under Section 4. This Agreement is not regulated by the California Department of Managed Health Care and is not a Knox-Keene licensed health plan.

Care is delivered via telehealth in accordance with California Business and Professions Code Section 2290.5. The Patient consents to telehealth care, subject to a separate Telehealth Informed Consent form. All clinical communication occurs through the Practice's HIPAA-compliant secure messaging platform.

Standard SMS text messages and email are NOT HIPAA-compliant and are NOT encrypted. The Practice will not send protected health information by standard text or email, and the Patient agrees to use only the secure messaging platform for clinical communication.

The Practice's liability for any claim related to these services (distinct from medical malpractice claims, which are governed by California law) shall not exceed the total fees paid by the Patient for the visit giving rise to the claim. This Agreement is governed by California law. Disputes shall be resolved first by good-faith negotiation, then by binding arbitration in San Diego County, except either party may seek injunctive relief in court.

This Agreement, together with the Telehealth Informed Consent and any applicable medication informed-consent form, constitutes the entire agreement. It may be amended only in writing, except the Practice may modify its fees or services on a prospective basis with reasonable notice. If any provision is unenforceable, the remainder stays in effect.

By signing below, the Patient acknowledges they have read, understood, and agree to this Agreement, including the Medicare/Medicaid eligibility attestation (Section 5), the visit fees and payment terms (Section 4), the cancellation and no-show policy (Section 4.5), the costs billed separately (Section 4.3), the cash-pay and superbill model (Section 4.2), and the disclosure that these services are not insurance (Section 9).

Confidential - North County Endocrinology Associates - www.ncendocrinology.com