Patient Agreement

PATIENT AGREEMENT

 This PATIENT AGREEMENT (this “Agreement”) is made by and between Personal Endocrine P.C., a California professional corporation company doing business at 12231 Newport Ave., North Tustin, CA 92705 (“Personal Endocrine”) and an individual (Patient).

1. Personal Endocrine provides professional medical services in endocrinology, diabetes, and metabolism (“Services”).

2. Patient desires that Personal Endocrine provides, and Personal Endocrine desires to provide, such Services in accordance with the terms and conditions set forth herein.

 NOW, THEREFORE, in exchange for good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows:

1. No Medicare Reimbursement. If you are a Medicare or Medicaid beneficiary, it is important for you to understand that the items and services provided by Personal Endocrine will not be covered by Medicare or Medicaid and that neither you nor Personal Endocrine may submit a claim to Medicare or Medicaid for any items or services you receive.

2. Service Defined. The meaning of the term “Services” shall include any physician-delivered medical care rendered at a scheduled consultation or follow-up visit. Such consultation or visit may be in person or by video-and-audio or audio-only call. Services do not include in-patient care, and Personal Endocrine will not admit, treat, or follow Patient at any hospital should Patient need the services of a hospital.

3. Fee-for-Service. You agree to be treated on a ‘fee-for-service’ basis. You agree to pay in advance for any Service performed at the start of each visit.

4. Other Fees. You agree to pay for any itemized charges not addressed by those fees outlined under Exhibit C, which is incorporated herein. You will be made aware of the fees for these services in advance of the services being performed. Payment for these services is due at the time services are rendered.

5. Membership. Personal Endocrine offers its patients enrollment in a membership program. You may enroll in our membership program by executing the Membership Agreement, attached to this agreement as Exhibit A and incorporated herein, the terms of which supersede, govern, and control all terms of this Agreement. It is not necessary for you to enroll in the membership program to be a patient of Personal Endocrine.

6. Medication.  Personal Endocrine has certain routine medications in stock and may dispense those medications to patient as a matter of convenience if Patient chooses to receive them directly from Personal Endocrine. Any medications dispensed by Personal Endocrine are not covered by the fees due under this Agreement. Patient acknowledges and agrees that Patient is responsible for the cost of any medications dispensed directly to patient and that the costs of said medications are not included as part of the Services and, thus, not covered by the fees due by Patient under this Agreement. Personal Endocrine will inform Patient of the cost of any medication prior to dispensing so that Patient may make an informed decision as to whether to pay for those medications or to have Patient’s prescription filled at a pharmacy of his or her choice.  

7. Limitations on Prescriptions for Controlled Substances. Personal Endocrine may prescribe certain controlled substances to patient from time to time as it deems medically appropriate. However, Personal Endocrine does not provide long-term chronic pain management and Personal Endocrine will not prescribe controlled substances on an on-going basis. Should Patient need long-term chronic pain management, Personal Endocrine can recommend another provider to assist Patient in the care and treatment of his or her pain management issues.    

8. E-mail. Members may communicate with Personal Endocrine physicians by e-mail for the purpose of medical care. To use e-mail, Patient must execute a consent form, set forth as Exhibit D. Such communications carry additional charges. Current rates for such communications are set forth in Exhibit C. These rates may be adjusted by Personal Endocrine at its sole discretion from time to time. Personal Endocrine will not provide you with notice of such change unless the change in rate is an increase of 20 percent or more from the prior rate, in which case Personal Endocrine will provide notice following the notice requirements of a change in fee amounts set forth under Section 16 below. If Patient desires to use e-mail, he or she shall provide such e-mail address beside his or her signature on Exhibit D. It is Patient’s responsibility to keep such information current and up-to-date, and to provide notice to Personal Endocrine of any change. Patient understands that there is always a possibility that a third party may gain unauthorized access to e-mail. Patient agrees that if he or she desires to use e-mail, he or she must execute an E-Mail and Text Message Consent form, located at Exhibit D. E-mail is not an appropriate means of communication for an emergency or a time-sensitive issue. During an emergency, or if a situation is reasonably expected to develop into an emergency, Patient should call 9-1-1 or go to the nearest emergency care facility.

9. Term. The “Term” of this Agreement shall commence on the date of your signature provided below. The Term shall continue until terminated by either party.

10. Termination. Personal Endocrine may terminate this Agreement for any reason (including no reason at all) and at any time, with or without notice. You may terminate this Agreement for any reason only upon 30-days’ written notice to Personal Endocrine.

11. Insurance; Reimbursement. PATIENT UNDERSTANDS AND ACKNOWLEDGES THAT PERSONAL ENDOCRINE DOES NOT PARTICIPATE IN ANY INSURANCE PROGRAM, PAYOR, OR REIMBURSEMENT SYSTEM, SUCH AS HMO PLANS WITH THE EXCEPTION OF MEDICARE. NO FEES, CHARGES, OR ANY OTHER AMOUNTS OWED OR PAID BY YOU SHALL BE REIMBURSABLE THROUGH A SYSTEM OR COVERABLE UNDER A POLICY. THIS AGREEMENT IS NOT INTENDED TO REPLACE ANY HEALTH INSURANCE PLAN OR COVERAGE PATIENT MAY CARRY. PATIENT UNDERSTANDS AND ACKNOWLEDGES THAT PERSONAL ENDOCRINE DOES NOT ACCEPT HEALTH INSURANCE OR MEDICARE AND WILL NOT BILL OR SUBMIT ANY CLAIM FOR SERVICES RENDERED UNDER THIS AGREEMENT. PATIENT UNDERSTANDS AND ACKNOWLEDGES THAT THE FEES PAID UNDER THIS AGREEMENT ARE NOT COVERED BY ANY HEALTH INSURANCE PLAN OR COVERAGE, INCLUDING MEDICARE, PATIENT MAY CARRY. MEDICARE CANNOT BE BILLED FOR ANY SERVICES PERFORMED FOR PATIENT BY BRIGHT ENDOCRINOLOGY. PATIENT AGREES NOT TO BILL MEDICARE OR ATTEMPT REIMBURSEMENT FOR ANY SUCH SERVICES.

12. Technical Failure; Force Majeure.

1. Neither Personal Endocrine nor any of its members, employees, or contractors shall be liable for any loss, injury, or expense arising from, or related to, any delay in responding to patient if such delay is caused by a technical failure. To remove any possible doubt, examples of technical failure include, without limitation: (a) Failure caused by an internet or cell phone issue; (b) Power outages; (c) Failure of an electronic messaging software or e-mail service; (d) Interception of communications by an unauthorized third party; (e) Issues caused by ransomware or malware; or (f) Failure by Patient to comply with any term or condition of this Agreement or any other agreement between Personal Endocrine, its affiliates, its vendors, or its contractors and Patient.

2. Whenever a day is appointed herein on which, or a period of time is appointed within which, either party is required to do or complete any act, matter, or thing, the time for doing or completion thereof shall be extended by a period of time equal to the number of days on or during which such party is prevented from, or is interfered with, the doing or completion of such act, matter, or thing because of strikes, lock-outs, embargoes, epidemic, and/or pandemic proportions (including, without limitation, Covid-19) or other causes affecting the areas where Personal Endocrine does business, the imposition of federal, state, or local governmental authorities of “shelter in place” or quarantine restrictions, unavailability of labor or materials, wars, insurrections, rebellions, civil disorder, declaration of national emergencies, acts of god, or other causes beyond such party’s reasonable control. Notwithstanding the foregoing, Patient shall be responsible, notwithstanding any force majeure event, to pay all amounts owed to Personal Endocrine timely.

13. Physician Absence. Patient understands that Personal Endocrine physicians or other staff may be unavailable from time to time. To remove any possible doubt, examples of reasons for absence of a physician include, without limitation: (a) Vacation; (b) Illness; (c) Childbirth or maternity leave; or (d) Personal emergency. In the event an absence is unexpected, Personal Endocrine shall make an effort, if possible, to notify Patient so Patient may re-schedule. If Patient experiences an acute medical issue requiring immediate attention, Patient should proceed to a facility which provides emergency medical care or urgent care. Notwithstanding any of the foregoing, Personal Endocrine in no way shall be liable to patient for a physician absence or for failure to timely notify Patient of such absence if the reason for the failure to notify Patient was outside Personal Endocrine’s reasonable control. Neither shall Personal Endocrine be responsible for, or liable to patient for, any amounts arising out of treatment provided by an emergency medical care or urgent care facility.

14. Compliance with Laws. The parties enter into this Agreement with the intent of conducting their relationship in full compliance with applicable federal, state, and local laws, including, without limitation, the Health Insurance Portability and Accountability Act, the Anti-Kickback Statute, and the Stark Law. Both parties agree and certify that neither party shall violate the Anti-Kickback Statute in performing under this Agreement. Notwithstanding any unanticipated effect of any provisions of this Agreement, neither party will intentionally conduct itself under the terms of this Agreement in a manner that would violate any such law. Nothing in this Agreement, nor any other written or oral agreement, nor any consideration in connection with this Agreement, contemplates or requires or is intended to induce or influence the admission or referral of any patient to or the generation of any business between Personal Endocrine and any other person or entity. This Agreement is not intended to influence any physician’s professional judgment in choosing the appropriate care and treatment of patients.

15. Dispute Resolution. In the event a dispute arises between or among the parties, the claimant party shall provide notice of dispute to the other party. Such notice shall set forth with reasonable particularity the factual basis and legal theory underlying the dispute, as well as a proposed remedy. The parties shall enter a 30-day dispute resolution period, where they shall make a good-faith effort to resolve such dispute. If the parties are unable to resolve their dispute, then, after the 30-day period ends, the claimant party may file its claim in a court of competent jurisdiction. Notwithstanding any of the foregoing, this section shall not apply to claims for amounts due and owing to Personal Endocrine which Patient has failed to pay in breach of this Agreement or any other agreement between Personal Endocrine and Patient. For such claims, Personal Endocrine may file its claims in court at any time, with or without attempting dispute resolution.

16. Fee Amounts. Fee-for-service fees are listed in Exhibit C, which is incorporated herein. Personal Endocrine reserves the right, at its sole discretion, to change those fees, provided Personal Endocrine provides Patient with 30 days’ notice of such change. During that 30-day notice period, Patient may provide notice to Personal Endocrine that he or she does not consent to such changes, upon which this Agreement shall automatically terminate at the last day of the month Patient provides such notice of non-consent. If Patient does not provide notice of non-consent within the 30-day period, such changes shall be deemed irrevocably accepted by Patient and binding upon the parties.

17. Change of Law. If any change in law, regulation, or rule (such as a change in an applicable healthcare law or reimbursement system) affects the legality of any material term of this Agreement (including any exhibits herein, such as, without limitation, the Membership Agreement set forth as Exhibit A, if that Membership Agreement is executed by the parties), this Agreement does not automatically terminate. Personal Endocrine may, at its sole discretion, either terminate this Agreement or modify this Agreement so that the transactions contemplated hereby be consummated.

18. Severability. If any term or provision of this Agreement is invalid, illegal, or unenforceable in any jurisdiction, such invalidity, illegality, or unenforceability shall not affect any other term or provision of this Agreement or invalidate or render unenforceable such term or provision in any other jurisdiction. Upon a determination that any term or provision is invalid, illegal, or unenforceable, a court may modify this Agreement to give effect to the original intent of the parties as closely as possible in order that the transactions contemplated hereby be consummated as originally contemplated to the greatest extent possible.

19.  No Oral Amendments. No amendment to or rescission, termination, cancellation, or discharge of this Agreement is effective unless it is in writing, identified as an amendment to or rescission, termination, cancellation, or discharge of this Agreement and signed by both parties.

20. Notice. Each party shall deliver all communications in writing either in person, by certified or registered mail, return receipt requested, by recognized overnight courier service, or by e-mail, addressed to the other party.  The address of Personal Endocrine is: 12231 Newport Ave., North Tustin, CA 92705.  Email: admin@personalendocrine.com.  The address of patient is such address and/or e-mail address set forth below the Patient’s signature.

21.  Governing Law; Jurisdiction. This Agreement, and all matters arising out of this Agreement, including tort and statutory claims, are governed by, and construed in accordance with the laws of the State of California, including its statute of limitations and choice-of-law statutes, without giving effect to any conflict-of-laws provisions thereof that would result in the application of the laws of a different jurisdiction. Either party shall institute any legal suit, action, or proceeding arising out of, or relating to, this Agreement in the federal or state courts.

22. Integration. This Agreement contains the entire understanding of the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous written or oral understandings, agreements, representations, and warranties with respect to such subject matter.

23. Assignment. Patient may not directly or indirectly assign, transfer, or delegate any of its rights or obligations under this Agreement, voluntarily or involuntarily, without the prior written consent of Personal Endocrine. Any purported assignment by Patient in violation of this section shall be null and void. Personal Endocrine may assign, transfer, or delegate any of its rights or obligations under this Agreement at any time, with or without notice to patient.

24. Inurement; Third-Party Beneficiaries. This Agreement is binding upon and inures to the benefit of the parties and their respective successors and permitted assigns. Except for the parties, their successors and permitted assigns, there are no third-party beneficiaries under this Agreement

25. Survival. Any section of this Agreement which, in order to give proper effect to its intent, should survive the expiration or termination of this Agreement, will survive such expiration or termination.

26. Counterparts. This Agreement may be executed in counterparts.