This Private Practice-Patient Agreement ("Agreement") specifies the terms and conditions under which, you, the undersigned patient ("Patient") may voluntarily elect to participate in the healthcare services offered by Dr. Mirna Jadan, MD ("Practice") as described in Schedule A and summarized as follows:
- Practice's Hormone Therapy Services (collectively "Hormone Therapy Services"); and
- An online health data storage and communication facilitation platform plan designed to provide efficient and reliable electronic communication and health data storage support for Hormone Therapy Services and to help Patient achieve Hormone therapy-based health goals ("Health Data Services").
Hormone Therapy Services and the Health Data Services described in Schedule A are collectively the "Hormone Therapy Services" and Patient and Practice are referred to individually as "Party" or collectively as the "Parties."
HORMONE THERAPY SERVICES
Practice makes Hormone Therapy Services available to Patient in exchange for Patient's payment of the program subscription fees outlined in Schedule A ("Services Fees"). Services Fees may increase from time to time with Patient's voluntary consent in advance but will apply to renewal terms. If Services Fees increase, Practice will notify Patient in writing with the option to consent to the increase. Practice reserves the right to update the Hormone Therapy Services in Schedule A from time to time, and if it does, Practice will notify Patient of any changes within thirty (30) days after a change is made and shall secure Patient's voluntary consent to any such modification of Hormone Therapy Services.
PAYMENT OPTIONS
Patient may pay the Services Fees with a credit card either monthly, bi-annually, or annually. Services are designed to allow Patient to pay Services Fees with health saving account ("HSA") funds or with flexible spending account ("FSA") or health reimbursement account ("HRA") funds, but Patient must confirm eligibility with Patient's tax expert or FSA/HRA plan coordinator as Practice cannot guaranty eligibility due to variable factors applicable to each Patient. Services Fees cover the availability of the Integrative Exam Services selected by and subscribed to by Patient for a period of one (1) year.
RENEWALS AND TERMINATION
This Agreement will automatically renew one (1) year from the date of this Agreement unless the Practice receives written notice from Patient to terminate this Agreement thirty (30) days before Patient's renewal date or Practice terminates the Agreement. Failure to pay the renewal Services Fees before the expiration of the prior period may result in termination of this Agreement. The Practice is permitted to terminate this Agreement with thirty (30) days prior written notice to Patient, in which case Patient will receive a prorated refund of the Services Fees but the delivery of any Integrative Exams renders Services Fees substantially earned by Practice.
HEALTH CARE SERVICES EXCLUDED FROM SERVICES FEES
Services Fees cover only the availability of Hormone Therapy Services subscribed to by Patient as described in this Agreement and Schedule A. If the Practice provides services other than the Hormone Therapy Services described in this Agreement and listed in Schedule A, the Parties may agree upon any additional charges. Patient acknowledges that Patient will be responsible for such additional charges for services outside of Services. Any charges to Patient for any services outside of Hormone Therapy Services will be at Practice's usual, reasonable and customary rates with Patient's advance consent. Costs for all services other than Hormone Therapy Services are the sole responsibility of the Patient.
ELECTRONIC COMMUNICATIONS
If Patient wishes to communicate through electronic mediums with Practice, Patient needs to be aware that electronic communications may not always constitute a secure medium for sending or receiving sensitive personal health information. Practice will take reasonable steps to keep Patient's communications confidential and secure and comply with applicable health data privacy obligations under applicable laws.
APPOINTMENTS AND SCHEDULING
Appointments with the Practice are scheduled through the Practice office to ensure ample time is given to each Patient. If Patient has an urgent concern, Patient shall call the Practice office and Patient will be given an appointment that will accommodate the urgency.
VACATIONS AND ILLNESS FOR PRACTICE PHYSICIANS
Patient acknowledges that there may be times that Patient cannot contact a Practice healthcare professional due to vacations or illness, or due to technical defects with either Patient's or Practice's electronic communication equipment. Patient acknowledges that, should a Practice healthcare professional become unavailable, the Practice shall make every effort to give advance notice to Patient so that scheduled Integrative Exam Services can be scheduled on another date. In all cases of emergency, Patient must call 9-1-1 and/or seek emergency/ER medical attention.
COMPLIANCE WITH LAW
In establishing the Integrative Exam Services programs, Practice intends to do so in compliance with all applicable laws. This Agreement shall be governed by and construed in accordance with the laws of the state in which Practice is licensed and practicing, without application of choice-of-law principles.
SCHEDULE A - HORMONE THERAPY VISITS & SERVICES FEES
Hormone Therapy Visits
Practice will provide Patient the availability of one (1) virtual appointment up to one (1) hour per month in regards to hormone therapy. Practice will provide coverage of labs as determined by need based on Provider discretion. Practice will allow communication via OhMD app or equivalent app. Provider will respond to messages as soon as possible during business hours. Discussion of other topics besides hormone therapy may and often do require a separate appointment outside of this package.
Cost of service is $150/mo.
SCHEDULE B - CONSENT FOR INTEGRATIVE SERVICES
Hormone Therapy Services and related supportive services may include, at the election of Patient, additional integrative services that are outside of and different than strictly allopathic healthcare services. Patient has reviewed and understands all of the following with respect to such services.
GENERAL STATEMENTS ABOUT HORMONE THERAPY SERVICES:
Hormone Therapy Services may assist with the restoration of health and optimal functional capacity, relief of pain and symptoms, injury and disease recovery, and prevention or reversal of disease or disease progression. But this is not guaranteed, as Patient's health outcomes depend on a wide range of variable factors. No healthcare services (including Hormone Therapy Services) are guaranteed to provide positive results. In fact, Hormone Therapy Services pose risks and may cause potential complications. Practice's healthcare professional has explained those risks and potential complications, and this Schedule B is intended to confirm Patient's acknowledgment of those explanations and to confirm Patient's informed consent to Integrative Services Patient elects to receive. Practice has not promised or guaranteed any specific benefits from the administration of Hormone Therapy Services and has made no warranty or guarantee about the results of any such treatment. Patient has weighed the benefits of, and alternatives to, Hormone Therapy Services. Practice's healthcare professional cannot know or anticipate and explain every possible risk or complication that may connect to Hormone Therapy Services. Patient willingly and voluntarily consents to any Hormone Therapy Patient elects to receive from Practice with an understanding there is no guarantee of benefits, and there is the potential for side effects and negative outcomes.
Please read the full agreement above carefully. By checking the box below and signing, you acknowledge that you have read, understood, and agree to the terms and conditions of this Private Practice-Patient Agreement.
