receive a reply acknowledging receipt. Any conversations occurring over the phone will be treated as if they had not occurred. 6. Disclosures. Member must disclose all of the following, but not limited to, the use of any products, treatments, or procedures that would react poorly with the treatments offered by Primal Health and received by member. Failure to disclose any of the above, shall constitute a full and complete waiver of liability on behalf of Primal Health, its staff, owners, affiliates, assigns, heirs, employees, contractors and related parties. Welcome Page 51 of 53
E. Payment Authorization In an effort to better serve you and simplify your billing experience, Primal Health requires credit card preauthorization for recurring monthly charges for programs on a payment plan. Charge card information is filed with your confidential information and kept secure. Accounts on file will be charged automatically each month upon the due date in accordance with the agreed upon invoice and installments as products and services come due. Accounts will be charged for additional services or products at time of purchase. We appreciate your prompt payment. I hereby authorize Primal Health and Wellness Clinic, PLLC to automatically charge my account each month all fees due under my membership agreement. I understand that my card will be charged each month on my membership date for upcoming fees and obligations. I hereby authorize Primal Health and Wellness Clinic, PLLC to automatically charge my account for all additional services and products at time of purchase that are not included in my monthly program fee. I understand that my card will be charged for additional services or products not included in my monthly program fees at time of purchase. PERSONAL GUARANTEE: I hereby irrevocably and unconditionally guarantee to Primal Health, the timely payment and performance of all of my liabilities and obligations pursuant to this agreement. Should I fail to pay charges when due, then after notice by Primal Health, I shall immediately cure my nonpayment in the same manner and as completely as I am obligated to do. My liability is direct, immediate, absolute, continuing, unconditional and unlimited. Primal Health shall not be required to pursue any remedies it may have against me as a condition to enforcement of this Guaranty, nor shall it be discharged or released by reason of the discharge or release of me for any reasons, including a discharge in bankruptcy, receivership or other proceedings. If, after a payment by credit card, you later dispute the charges, unless prohibited by law, you agree not to cancel, revoke, charge back, or dispute any previously entered charge on your credit card. If you do so, and it is later determined that the charge was properly authorized, you agree to pay all out of pocket fees and costs incurred by the Primal Health as a result of the improper cancellation, revocation, charge back, or dispute. Insurance Declination I understand that Primal Health and Wellness Clinic, PLLC. has opted out of all insurance programs. Primal Health and Wellness Clinic, PLLC is a “cash-based” practice that does not bill insurance carriers, including Medicare, even if services rendered and products sold are covered by privately held insurance program. Primal Health and Wellness Clinic, PLLC will provide standard invoicing for patient records but will not generate or respond to requests for “super bills” for patient initiated insurance reimbursement. Welcome Page 52 of 53
F. Treatment Guidelines and Primary Care Requirements Primal Health and Wellness Clinic, PLLC specializes in health-span management through a functional and integrative approach to hormone optimization. Our primary area of expertise and focused therapeutic objective is hormone management. In order to treat hormone dysfunction, your provider may recommend intervention in a number of secondary therapeutic domains. These secondary therapeutic domains may overlap with services provided through a traditional “family doctor” or primary care provider. Some examples of secondary therapeutic domains are sexual dysfunction, weight-loss management, high blood pressure and cholesterol management, and blood glucose (diabetes) management. It is important to keep in mind, however, that the primary purpose of intervening in these secondary therapeutic domains is to achieve maximum hormone optimization. Our singular focus on hormone optimization means that despite potential overlap in treatment domains with your primary care provider, we ARE NOT a substitute for your primary care provider and their expertise in primary care medicine. As an example, we do not offer routine acute care services, in office general care procedures, appropriate and necessary cancer screenings, general wellness examinations, specialty referrals, L&I and FMLA services, etc. We operate as a specialty provider and do not have the capability to provide care for you as a primary care provider. All of our membership tiers (Primal Foundations, Primal Flex, and Primal Flagship) have hormone optimization as the primary goal. The number of hormone axes and the number and complexity of secondary therapeutic domains of intervention determine the level of membership you are required to maintain in order to work with our providers. In some cases, our providers may feel comfortable managing secondary therapeutic domains in order to optimize your hormone profile. In general, however, you will be expected to establish care with a primary care physician or specialist for management. In all cases, for patients 65 years and older, you will be required to maintain an active relationship with a primary care provider. For members 65 and over, our providers will only manage our primary area of expertise, hormone optimization, and all other healthcare domains will be required to be addressed by your primary care provider. Welcome Page 53 of 53
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