North County Endocrinology Associates

NCEA Direct Membership Agreement
North County Endocrinology Associates
Endocrinology · Obesity Medicine · Metabolic Health & Longevity
www.ncendocrinology.com
NCEA DIRECT MEMBERSHIP AGREEMENT
Premium Endocrinology & Metabolic Health Membership
Patient name (Full name)
Date of birth

MonthDayYear
Date
Email
example@example.com
Phone
Format: (000) 000-0000.
Membership
NCEA Direct — $189 / month
Start date

MonthDayYear
Date
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NCEA Direct Membership Agreement
1. Purpose and Parties
This NCEA Direct Membership Agreement ("Agreement") is between North County Endocrinology Associates, a California Professional Corporation ("Practice"), and the patient named above ("Member"). It establishes the terms under which the Practice provides enhanced, physician-led endocrinology and metabolic health membership services, delivered primarily via telehealth across California.
This membership covers enhanced access and care-coordination services that are not separately billable to insurance. It is NOT insurance, does NOT replace insurance, and does NOT cover the cost of clinical visits, medications, laboratory testing, or imaging.
2. Services Included in Membership
The NCEA Direct membership includes the following enhanced, physician-led services, provided primarily through the Practice's HIPAA-compliant secure messaging platform and telehealth:
- Priority appointment access, including a 48-hour appointment guarantee for non-urgent requests (Monday-Saturday, excluding major holidays and scheduled physician absences)
- Direct secure messaging with the physician via a HIPAA-compliant platform
- Asynchronous (between-visit) medical management and clinical guidance
- Medication review, adjustment, and optimization between visits
- Remote insulin pump management and support, where applicable
- Advanced continuous glucose monitor (CGM) data interpretation
- Laboratory result interpretation and personalized guidance
- Insurance prior authorization submission and appeals support
- Coordination of care across specialists and providers
- Enhanced after-hours availability for established members
- An annual Personal Health Maintenance Blueprint summarizing recommended screenings and metabolic health goals
- A personalized metabolic health and healthspan roadmap
The membership does NOT include the cost of clinical visits, medications, laboratory testing, or imaging. These are billed separately as described in Section 4.
3. Clinical Model
3.1 Care Delivery
Membership services are delivered primarily through secure messaging and telehealth, supplemented by in-person or video clinical visits as clinically indicated. The membership enhances access to and coordination of the Member's care; it does not replace clinically necessary visits.
3.2 Relationship to Standard Medical Care
The Member is expected to maintain a standard patient relationship with the Practice for clinically necessary medical services, which are billed to the Member's insurance or at applicable cash-pay rates. The membership services are supplemental and are provided outside of, and in addition to, services billable to insurance or any government program.
3.3 No Guarantee of Outcome
Enrollment in this membership does not guarantee any particular medical outcome, diagnosis, treatment, prescription, or result. All clinical decisions remain subject to the physician's independent medical judgment. Individual results vary.
www.ncendocrinology.com
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NCEA Direct Membership Agreement
4. Membership Fee and Billing
4.1 Membership Fee
The NCEA Direct membership fee is $189 per month. The fee is a retainer for enhanced access and care-coordination services and is not prepayment for, or a substitute for, billable medical care.
4.2 Billing
The membership fee is billed monthly to the payment method on file, beginning on the start date and recurring on the same day each month. The membership continues month-to-month until cancelled as described in Section 6.
4.3 Visit, Medication, and Testing Costs (Not Included)
The following are billed separately and are NOT included in the membership fee:
- Clinical visits (in-person or video) — billed to the Member's insurance, or at applicable cash-pay rates
- Medications — covered by the Member's insurance (subject to copay) or paid out of pocket
- Laboratory tests and imaging—billed separately and may be covered by insurance
4.4 Relationship to Insurance and Government Programs
The membership fee is charged only for enhanced, non-billable access and care-coordination services that are not covered or reimbursable by insurance or any government healthcare program. The Practice will continue to bill insurance for all clinically necessary, covered services in the ordinary course. The membership does not waive, replace, or affect any insurance cost-sharing obligations.
5. Member Responsibilities
- Provide accurate, complete medical history and disclose all medications and conditions
- Maintain a valid payment method on file
- Attend clinically indicated visits and complete recommended monitoring and laboratory testing
- Use the HIPAA-compliant secure messaging platform for all clinical communication
- Report concerning symptoms, side effects, or adverse reactions promptly
- Not rely on the membership for emergency care — call 911 in an emergency
- Maintain comprehensive health insurance and an established primary care provider
6. Term and Cancellation
This Agreement begins on the start date and continues on a month-to-month basis. Either party may cancel with 30 days' written notice. The Member remains responsible for the membership fee through the end of the notice period. Membership fees already paid are non-refundable except as required by law.
The Practice may terminate this Agreement for non-payment, abusive conduct, clinical inappropriateness of continued membership, or any reason with 30 days' notice. Termination of the membership does not terminate the Member's underlying patient relationship for clinically necessary care.
7. Important Disclosures
This membership is NOT health insurance, is NOT a substitute for health insurance, and does NOT satisfy any requirement to maintain health insurance. The Member should maintain comprehensive health insurance independently.
www.ncendocrinology.com
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NCEA Direct Membership Agreement
The membership fee is a retainer for enhanced access and care-coordination services and is not prepaid
medical care. This Agreement is not regulated by the California Department of Managed Health Care and
is not a Knox-Keene licensed health plan.
8. Communication and Privacy
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 Member agrees to use only
the secure messaging platform for clinical communication.
www.ncendocrinology.com
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NCEA Direct Membership Agreement
9. Telehealth Informed Consent
This section is a distinct informed consent for telehealth care, provided in accordance with California Business and Professions Code Section 2290.5, and requires the Member's separate acknowledgment and signature at the end of this section.
9.1 Nature of Telehealth
Telehealth is the delivery of health care services using interactive audio, video, or data communications, including the asynchronous (store-and-forward) transmission of medical information that the physician reviews at a later time. A substantial portion of the Member's membership services will be delivered through secure messaging and telehealth.
9.2 Benefits and Limitations
Telehealth offers improved access, convenience, and continuity of care. It also has limitations: the physician cannot perform a hands-on physical examination by telehealth; technology failures or delays may occur; and in some circumstances information transmitted may be insufficient for clinical decision- making, requiring an in-person visit. No electronic transmission is completely secure, and there is a small residual risk to privacy despite reasonable safeguards.
9.3 The Member's Rights
The Member may withdraw consent to telehealth at any time without affecting their right to future care, and may request in-person care at any time. The same standards of care, confidentiality, and privacy protections that apply to in-person care apply to telehealth care.
9.4 Emergencies
This membership and the secure messaging platform are NOT for emergencies and are not monitored continuously. In a medical emergency, the Member must call 911 or proceed to the nearest emergency room.
Telehealth Consent Acknowledgment: By signing below, the Member acknowledges they have read and understood this Telehealth Informed Consent, have had the opportunity to ask questions, and consent to receiving care via telehealth, including asynchronous care, as described above.
Member signature - Telehealth Consent
Date

MonthDayYear
Date
10. Liability, Governing Law, and General Provisions
The Practice's liability for any claim related to membership services (distinct from medical malpractice claims, governed by California law) shall not exceed the total membership fees paid in the preceding twelve months. 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.
www.ncendocrinology.com
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NCEA Direct Membership Agreement
This Agreement, together with any incorporated consents, constitutes the entire agreement. It may be amended only in writing, except the Practice may modify services or the membership fee with 30 days' notice. If any provision is unenforceable, the remainder stays in effect.
Acknowledgment and Signature
By signing below, the Member acknowledges they have read, understood, and agree to this Agreement, including the monthly membership fee (Section 4.1), the separate billing of visits, medications, and testing (Section 4.3), the Telehealth Informed Consent (Section 9), and the disclosure that this membership is not insurance (Section 7).
Member signature
Date

MonthDayYear
Date
Member printed name
Date of birth

MonthDayYear
Date
Jamil Alkhaddo
Date

MonthDayYear
Date
Physician signature — Jamil Alkhaddo, MD

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North County Endocrinology Associates

NCEA DIRECT MEMBERSHIP AGREEMENT

1. Purpose and Parties

2. Services Included in Membership

3. Clinical Model

3.1 Care Delivery

3.2 Relationship to Standard Medical Care

3.3 No Guarantee of Outcome

4. Membership Fee and Billing

4.1 Membership Fee

4.2 Billing

4.3 Visit, Medication, and Testing Costs (Not Included)

4.4 Relationship to Insurance and Government Programs

5. Member Responsibilities

6. Term and Cancellation

7. Important Disclosures

8. Communication and Privacy

9. Telehealth Informed Consent

9.1 Nature of Telehealth

9.2 Benefits and Limitations

9.3 The Member's Rights

9.4 Emergencies

10. Liability, Governing Law, and General Provisions

Acknowledgment and Signature

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