North County Endocrinology Associates
Endocrinology · Obesity Medicine · Metabolic Health
www.ncendocrinology.com

Membership plan: NCEA Direct Membership — $199 / month

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 physician-led endocrinology care on a membership basis, delivered via telehealth across California.

This membership covers physician medical management, the included telehealth visits described below, and care coordination. It is NOT insurance and does NOT cover the cost of medications, laboratory testing, or imaging.

The membership includes the following physician-led services, delivered by telehealth:

• An initial 60-minute video consultation to establish care and develop your treatment plan
• A follow-up video visit every three (3) months, plus additional visits when clinically indicated, at no additional visit fee
• Direct secure messaging with the physician between visits for questions, prescription refills, and dose adjustments that can be safely managed in writing
• Review of continuous glucose monitor (CGM) and glucose data for members managing diabetes
• Medication prescriptions and prior-authorization submission and appeals
• Ordering of laboratory testing and imaging (billed to the Member's insurance or the testing facility — see Section 4)
• An annual Personal Health Maintenance Blueprint — a comprehensive endocrine and health-maintenance evaluation to optimize health, longevity, and healthspan

The membership does NOT include the cost of medications, laboratory testing, imaging, or the administrative services described in Section 4.

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Care is delivered entirely by telehealth. After the initial video visit to establish the patient-physician relationship and treatment plan, ongoing care occurs through scheduled video visits and secure messaging. Additional video visits are scheduled when clinically indicated, as determined by the physician.

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

The membership fee is $199 per month. This is a flat monthly retainer for the included physician services described in Section 2.

The membership fee is billed to the payment method on file on the start date and automatically on the same day each month thereafter, until cancelled as described in Section 7. By enrolling, the Member authorizes recurring monthly charges to the payment method on file.

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

• Medications — sent to the Member's pharmacy and covered by the Member's insurance or paid by the Member
• Laboratory testing and imaging — ordered to the Member's usual laboratory or facility and billed to the Member'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

Patients who are not members may obtain care on a pay-per-visit basis (initial consultation $349; follow-up visit $174). Members are not charged these per-visit fees for the visits included under Section 2.

The membership and 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 Member an itemized superbill that the Member 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 Member's insurer, and the Practice does not guarantee any reimbursement.

The Practice will submit prior-authorization requests for medications to the Member's insurance as part of the membership. If coverage is approved, the Member is responsible for any applicable copay; if coverage is

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denied, the Practice will discuss alternatives. The Practice does not guarantee insurance approval or any particular cost.

This membership is available only to patients who are NOT beneficiaries of Medicare or Medicaid (Medi-Cal). By signing this Agreement, the Member attests that:

• The Member is NOT enrolled in Medicare (Part A or Part B) or Medicaid / Medi-Cal; and
• The Member will promptly notify the Practice if the Member becomes enrolled in Medicare or Medicaid at any time during the membership.

If the Member is, or becomes, a Medicare or Medicaid beneficiary, the Member is not eligible for this cash-pay membership and the Practice will end the membership. The Member 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
• Maintain a valid payment method on file
• Attend the initial video visit and any clinically indicated follow-up visits
• Use the HIPAA-compliant secure messaging platform for all clinical communication
• 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 the membership for emergency care — call 911 in an emergency
• Promptly notify the Practice of any change in Medicare or Medicaid enrollment (Section 5)

This Agreement begins on the start date and continues month-to-month. The membership has a one-month minimum and the first month's fee is non-refundable. After the first month, the Member may cancel at any time by providing 30 days' written notice; the membership remains active, with full access, and the monthly fee continues through the 30-day notice period.

The Practice may terminate this Agreement for non-payment, abusive conduct, clinical inappropriateness of continued membership, loss of eligibility under Section 5, or any reason with 30 days' notice. The Practice may decline to provide a service or prescription where clinically inappropriate.

Secure messaging is included for questions, refills, and adjustments that can be safely managed in writing, alongside the Member's scheduled visits. Membership is intended for the ongoing management of the Member's endocrine conditions and is not a service for daily or urgent contact. Concerns that require an examination, evaluation of a new problem, or more detailed clinical decision-making will be addressed in a scheduled visit, consistent with the standard of care. Membership is not a substitute for primary care or for urgent or emergency services. For a medical emergency, call 911.

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This membership is NOT health insurance. It does not satisfy any requirement to maintain health insurance, and the Member should maintain comprehensive health insurance independently.

The membership fee is a retainer for physician medical management and the included services and is 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 Member 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 Member agrees to use only the secure messaging platform for clinical communication.

The Practice's liability for any claim related to membership services (distinct from medical malpractice claims, which are 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.

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 services with 30 days' notice. If any provision is unenforceable, the remainder stays in effect.

By signing below, the Member acknowledges they have read, understood, and agree to this Agreement, including the Medicare/Medicaid eligibility attestation (Section 5), the one-month minimum and 30-day cancellation terms (Section 7), the costs billed separately (Section 4.3), the cash-pay and superbill model (Section 4.4), and the disclosure that this membership is not insurance (Section 9).

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