Patient Acknowledgment and Agreement

1. Exclusions from Program Services
   The Patient acknowledges that the Physician will not provide, and the Program Services do not include, hospital services, emergency care, surgery and related surgical services, radiology, third-party services, and certain laboratory services. The Patient agrees to pay the Membership Fee for each Renewal Year prior to the start of each renewal period, and to pay the full invoiced amount or authorize an automated payment method within 30 days of receiving the invoice. In the event the Agreement is deemed invalid and a refund of the Membership Fee is required, the Patient agrees to pay the Practice an amount equivalent to the reasonable value of Program Services rendered before the refund is processed.

2. Excluded Health Care Services
   The Membership Fee and Visit Fee cover the cost of Program Services, but do not include health care services covered by insurance. The Physician and Practice make no representations regarding insurance coverage for any fees paid under this Agreement. The Patient remains financially responsible for any health care services not covered by their insurance.

3. Insurance or Medical Coverage
   The Patient acknowledges that this Agreement is not an insurance plan and does not substitute for health insurance or other coverage. The Patient is advised to maintain suitable health insurance policies for general healthcare needs. The Program Services provided under this Agreement are not covered by Medicare, Medicaid, or any other third-party payer, and the Practice and Physician have opted out of Medicare. If the Patient is or becomes eligible for Medicare, they acknowledge that the Physician cannot bill Medicare for any services rendered.

4. Designated Physician
   Program Services will be provided by the designated Physician, who may, at times, designate a qualified covering physician or licensed medical professional. The Practice will offer appointments on a first-come, first-served basis, with exceptions for urgent medical needs as determined by the Physician.

5. Term and Termination
   This Agreement has an initial term of one year, commencing on the Effective Date. It may be renewed annually, unless either party opts not to renew by providing written notice 30 days before the end of the current term. The Agreement may be terminated as follows:

   • By the Patient: The Patient may terminate with 30 days' notice but will not be entitled to a refund unless specified elsewhere in the Agreement.
   • By the Patient (Relocation): If the Patient moves outside the Practice’s service area, they may terminate immediately.
   • By the Practice: The Practice may terminate the Agreement due to a breach by the Patient or non-payment of outstanding balances, or with 30 days’ notice for any other reason, with or without cause. In such cases, the Patient may receive a prorated refund.
   • The Agreement will terminate automatically upon the death or dissolution of either party.

6. Communications
   The Patient authorizes the Physician and Practice staff to communicate via electronic means (such as email, text, and the patient portal) regarding protected health information (PHI). Electronic communication is not guaranteed to be secure, and the Patient acknowledges that PHI may be part of their medical record. Emergency and sensitive medical issues should not be communicated electronically; instead, the Patient should seek immediate medical attention.

7. Independent Medical Judgment
   The Physician retains full discretion to make medical decisions in the best interest of the Patient, and nothing in this Agreement should influence or limit the Physician’s independent medical judgment.

8. Amendments and Changes
   The Practice may amend this Agreement as necessary, including in response to changes in law. The Patient will be notified of such changes, which will become effective upon notice. Any other amendments must be made in writing and signed by both parties.

9. Governing Law and Dispute Resolution
   This Agreement will be governed by Texas law. Any disputes will be resolved exclusively through binding arbitration in Harris County, Texas, under the rules of the American Arbitration Association. Both parties waive their right to a jury trial.

10. Severability
    If any part of this Agreement is found to be invalid or unenforceable, the remainder of the Agreement will remain in effect.

11. Notice
    All communications related to this Agreement (except those regarding PHI) should be sent in writing to the addresses listed in this Agreement. Changes in address must be communicated according to these provisions.

12. Legal Significance
    The Patient acknowledges that this Agreement is a legally binding document and has had the opportunity to seek legal advice.

13. Entire Agreement
    This document constitutes the entire agreement between the parties, superseding all prior agreements. Any terms of usage designated by the Practice will take precedence over conflicting terms in this Agreement.

By signing below, the Patient agrees to all terms and conditions outlined in this Agreement.