Access Foxhall Membership Agreement

Access Foxhall Membership Agreement

This agreement (the “Agreement”) is made and entered into effective as of the day of (the “Effective Date”) by and among Foxhall Medicine, P.L.L.C. (“FHM”), and (“Patient”).

In consideration of the mutual promises and undertakings set forth below, and for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, Foxhall Medicine agrees to provide the Patient with the Program Services described in the Agreement on the terms and conditions set forth below.

Patient Information. The patient confirms that the information below is accurate and complete and agrees to notify FHM of any changes promptly.

Services. In consideration of the Annual Membership Fee, FHM agrees to provide the Patient with the following services:

• 24-hour Direct Access to your physician through a dedicated email address and phone number.

• Priority Appointment Scheduling.

• Facilitated Scheduling for testing, outside appointments, and specialist referrals.

• Same-day Prescription Refills.

• Facilitation of prior authorization for medications and medical testing as insurance requires.

• Collection and processing of medical records from other providers and facilities.

• Liaising with outside providers for patients with complex issues and all other administrative needs.

Membership Fees and Payments

Individual:

—Please choose an option—$1,000.00-Annual fee, paid in full upon enrollment and automatically renewed each year.$1,200.00-Annual fee, paid in automatic monthly payments of $100.00 and automatically renewed each year.

Couple:

—Please choose an option—$500.00-Annual fee, paid in full upon enrollment and automatically renewed each year.$600.00-Annual fee for spouse/partner, paid in automatic monthly payments of $50.00 and automatically renewed each year.

Membership will renew automatically each year unless a written cancellation request is received.

Health Care Services Excluded from Membership Fee. The annual fee covers the cost of the Program Services; however, the fee does not cover the cost of any healthcare services provided by Dr. Joshua S. Yamamoto. All visits and medical services will be billed to insurance and must be paid for at the time of service. Neither Physician nor Practice makes any representations whatsoever that any fees paid under this Agreement are covered by the Patient’s health insurance or other third-party payment plans applicable to the Patient. Nothing in this Agreement Supersedes or modifies the terms or conditions of any agreements related to your health insurance. The patient acknowledges that he/she is financially responsible for any health care services received, and payment is expected at the time of service.

Term and Termination. Unless earlier terminated as set forth below, the initial term of the Agreement shall be for one year, commencing on the Effective Date and renewing annually on the first anniversary of the Enrollment Date. Either party may decline to renew the agreement upon written notification to the other party no less than 30 days before the expiration of the Initial Year or the Renewal Year, as applicable.

The Agreement may be terminated as follows:

• The patient may terminate this Agreement at any time upon thirty (30) days prior written notice to the Practice. The patient will not be entitled to refund the Membership Fee or a portion thereof.

• Patient may terminate this Agreement immediately upon relocation to a new locality outside the area of the Practice and Physician.

• This Agreement automatically terminates upon the death or dissolution of the other Party.

Communications.The patient authorizes the Physician and Practice staff and designees to communicate with the Patient by e-mail regarding the Patient’s protected health information (“PHI” as defined in the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations) via the Patient’s cell phone and/or email address shown on this Agreement. Additionally, Patients can communicate with the Practice via email regarding test results or any other non-urgent medical issues. Email responses will typically be within 24 hours and no later than within two business days. Electronic Communication includes but is not limited to email, text (SMS, MMS, Instant Messaging), and audio or video conference.

The patient acknowledges and agrees that:

• Electronic Communication may not be secure for sending or receiving PHI.

• Although the Physician and Practice staff will make reasonable efforts to keep Electronic Communication with the Patient confidential and secure, the Patient understands that they cannot assure or guarantee the confidentiality of Electronic Communication.

• All Electronic Communication is part of the Patient’s permanent medical record.

• The patient will not use Electronic Communication for communications regarding emergencies, urgent medical problems, or other time-sensitive issues. In the event of an emergency or a situation that the Patient could reasonably expect to develop into an emergency, the Patient shall call 911 or proceed to the nearest emergency facility and follow the directions of emergency personnel.

• Neither the Physician nor any of the Practice’s agents, consultants, or representatives will be liable to the Patient for any loss, damage, cost, injury, or expense caused by or resulting from: (1) a delay in response to Patient due to technical failures, including but not limited to, technical failures attributable to the internet service provider, power outages, failure of electronic messaging software, failure by Physician, or any of Practice’s agents, consultants or representatives to adequately address Electronic Communication messages, failure of computers or computer networks, or faulty telephone or cable data transmission; (2) any interception of Electronic Communication by a third party; or (3) the Patient’s failure to comply with the guidelines regarding the use of Electronic Communication outlined in this Section.

Amendment. The Agreement contains the parties' entire agreement and supersedes all prior agreements and understandings between the Parties regarding the subject matter. The Agreement may only be amended by a written agreement signed by the Parties. Notwithstanding the foregoing, the Practice may amend this Agreement to the extent required by federal, state, or local law, rule, or regulation by sending the Patient thirty-day (30) advanced written notice of any such change. Any such changes are incorporated by reference into this Agreement without the need for signature by the parties and are effective as of the date established by the Practice, except that the Patient shall initial any such change at the Practice’s request.

Assignment. The patient may not assign the Agreement to another individual.

Entire Agreement. This Agreement contains the whole agreement between the parties and supersedes all prior oral and/or written understandings and agreements regarding the subject matter of this agreement.

IN WITNESS WHEREOF, the parties have executed this agreement, which will be effective on the Effective Date shown below.

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