This Membership Agreement (“Agreement”) is entered into and effective as of the day entered below (the “Effective Date”), by and between the person signing below (“Member” or “you”). MDVIP365 LLC Concierge Medicine, PLLC (“MDVIP365 LLC”) is DBA
Priority Medical Group (PMG).

RECITAL

MDVIP365 LLC provides primary care medical services to patients and employs MDVIP365 LLC (the “Licensed prescriber”) to provide the services defined in this Agreement. You desire to receive, in exchange for a fee, certain medical services (“Medical Services”) and non-medical services (“Non-Medical Services”) (collectively the “Services”) from MDVIP365 LLC as part of and by this Agreement. This Agreement aims to set forth the terms and conditions of how the Services will be furnished. You and MDVIP365 LLC, therefore, agree as follows:

Medical Services. MDVIP365 LLC will provide you with the Medical Services described in this Section 1. As used in this Agreement, the term Medical Services means only those primary care medical services that the Licensed prescriber is permitted to perform under the laws of the State of Arizona consistent with his training and experience as a primary care licensed prescriber. Generally, such services encompass health promotion, disease prevention, diagnosis, maintenance, and treatment of patients during health and all stages of illness, focusing on preventive care.

Annual In-Depth Wellness Examination. Payment of your Membership Fee includes an annual in-depth wellness physical examination and evaluation (“Wellness Evaluation”) provided by the Licensed prescriber at no additional charge. As part of the Wellness Evaluation, the Licensed prescriber will administer a panel of laboratory tests and then develop a personalized written health, exercise, and dietary health plan for you to follow. As this Agreement uses, “Wellness Evaluation” means a physical examination and wellness evaluation provided to you, not in connection with any illness or injury.

EXCLUSIONS: Your Membership Fee DOES NOT COVER, and you may incur additional out-of-pocket costs for hospitalization, surgical procedures, vaccines, medications, Botox®, X- rays, any diagnostic testing or lab work, pathology (pap smears, biopsies), emergency room visits, prenatal care, and other services not typically rendered by primary care licensed prescribers in their medical offices. You or your insurance will be responsible for paying all medical costs not covered by your Membership Fee.
Please Note: PMG can not treat all conditions & additional medical care may sometimes be required; PMG is not a chronic pain clinic.

Non-Medical Services. Payment of the Membership Fee will enable you to receive the following non-medical services and benefits usually not covered by insurance:

24/7 Access. You will have direct telephone access to the Licensed prescriber twenty-four hours a day, seven-day per week. You will be given a phone number to reach the Licensed prescriber directly around the clock. During the Licensed prescriber’s absence for vacations, continuing medical education, illness, emergencies, or days off, MDVIP365 LLC will provide the services of a substitute licensed prescriber, and you will be given instructions on how to contact the reserve licensed prescriber. The replacement licensed prescriber will be available to you to the same extent as the Licensed prescriber, although the substitute approved prescriber may be contacted through an answering service rather than directly.

Facsimile and E-Mail Access. You will be given the Licensed prescriber’s facsimile number and e-mail address to which non-urgent communications may be addressed. Such communications will be handled and responded to by the Licensed prescriber or a staff member of the Practice in a reasonably timely manner.

Please Note: If you are experiencing a life-threatening or emergency medical situation, you should NOT call the Licensed prescriber; instead, you should CALL 911 IMMEDIATELY.

Membership Fees and Payment. In exchange for the Services provided for in this Agreement, you agree to pay an annual membership fee (“Membership Fee”) to PMG in the amount specified on the attached Schedule “A.” You may elect to pay your Membership Fee annually, semi-annually, quarterly, or monthly. You will designate your selected payment plan on Schedule “A.” Membership Fee payments not received by their due date will cause your membership to become inactive.

The annual Membership Fee covers a period of one (1) calendar year starting on the Effective Date of this Agreement. The fee schedule is subject to change in subsequent years. Members will be notified of any fee increases upon annual membership renewal and may elect to only renew with a penalty. Your initial payment must be paid before your first visit. The Membership Fee is paid in addition to and not in exchange for copayments, deductibles, or coinsurances.

PMG reserves the right to assess a fee of $50.00 for any returned or declined check or ACH payment. If this occurs, the member will no longer be eligible to remit payment by check or ACH.

Members may add family members at any time during their membership, subject to available space. Membership fees are non-transferable. At least one parent must be an active member to have dependent membership.

Suppose either party terminates this Agreement upon written notice. In that case, you will be entitled to refund any unused portion of your Membership Fee, provided that the first $600.00 of your Membership shall be non-refundable and not refundable upon termination. If PMG terminates this Agreement for any reason, you will be entitled to a prorated refund of your annual Membership Fee, not including the first $600.00. Such prorated refunds will be based on the number of days you have been a member.

Medicare. You acknowledge that PMG and the licensed prescriber will not provide services to you covered by Medicare and will not bill Medicare or receive payment from Medicare for any services provided to you. To the extent you receive services covered by Medicare from any other provider, you will make arrangements with such provider for payment. Neither PMG nor the licensed prescriber makes any representations that the fees paid under this agreement are or are not covered by your health insurance or other third-party payment plans applicable to you or your family. You will have complete responsibility for any such determination.

Insurance; Member Responsibility for Other Medical Coverage. You or your insurance company will be responsible for paying for any medical, clinical, diagnostic, or therapeutic services or items provided to you outside of PMG. This Agreement is not a substitute for health insurance or other health plan coverage (such as membership in an HMO). You acknowledge that the Licensed prescriber has advised you to keep in full force (or to purchase) your health insurance policy(ices) or plans to cover you and your family members for healthcare costs not covered by your Membership Fee under this Agreement (or if this Agreement is terminated) and to prevent gaps in health coverage. This Agreement does not affect any applicable co-payments, coinsurance, or deductibles thereunder, which you must continue to pay under the terms of such insurance or program. The Member is responsible for paying deductibles, co-pays, and coinsurances associated with any charges from outside healthcare providers, facilities, and entities.

Communications. You acknowledge that communications PMG or the Licensed prescriber using e-mail, facsimile, and cell phone are not guaranteed to be secure or confidential methods of communication. As such, you waive the Licensed prescriber’s obligation to ensure confidentiality concerning correspondence using such means of communication. You acknowledge that all such communications may become a part of your medical records.

You authorize the Licensed prescriber to communicate with you by e-mail regarding your “protected health information” (PHI) (as that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulations) using the e-mail address you provide PMG. By providing PMG with your e-mail address, you acknowledge that:

E-mail is not a secure medium for sending or receiving PHI; if you send or receive e-mail through your employer’s e-mail system, your employer may have the right to review it.

Although PMG and the Licensed prescribers will make reasonable efforts to keep e-mail communications confidential and secure, neither PMG nor the Licensed prescriber can assure or guarantee the confidentiality of e-mail communications.

At the discretion of the Licensed prescriber, e-mail communications may be made a part of your permanent medical record; email is not an appropriate means of communication regarding emergencies and time-sensitive issues or inquiries regarding sensitive information.

If you do not receive a response to your e-mail message within two days, you agree to use another means of communication to contact the Licensed prescriber. Neither PMG nor the Licensed prescriber will be liable to you for any loss, cost, injury, or expense caused by or resulting from a delay in responding to you because of technical failures, including, but not limited to technical failures attributable to any internet service provider power outages or loss of any electronic messaging software.

Please adequately address e-mail messages.
Failure of PMG or the Licensed prescriber's computers or computer network, or faulty telephone or cable data transmission.

Any interception of e-mail communications by a third party, or your failure to comply with the guidelines regarding email communications outlined in this section.