Stonehaven Medical Group

Direct Primary Care (DPC) Practice Membership Agreement

This Agreement ("Agreement" is entered into on the date executed and signed by the DPC Patient listed below. This agreement by and between STONEHAVEN MEDICAL GROUP, PLLC, herein after referred to as the "DPC PRACTICE" and the DPC Patient.

WHEREAS, DPC PRACTICE provides Direct Primary Care medical services to DPC patient and If elected dependents of DPC patients directly and through affiliates; and

WHEREAS, DPC Patient and DPC PRACTICE wish to memorialize their agreement as set forth below;

THEREFORE, for good and valuable consideration the sufficiency and receipt of which is hereby acknowledged by the parties, the parties agree to the following terms and conditions:

1. Patient-Clinician Relationship
   By your signature, you acknowledge that you are voluntarily becoming a patient of the DPC PRACTICE and its medical group or affiliated clinical facllityles). As a DPC PRACTICE patient, those services described in Section 2 below will be made available to you pursuant to the terms of this Membership Agreement.

2. DPC PRACTICE Services
   Health Care Services: As a patient, you are eligible to receive a set of primary care, preventive care, and or urgent care services as offered by your individual DPC Practice from among those listed in our Detailed Service List attached below and also available on our DPC PRACTICE WEBSITE or at your DPC PRACTICE clinic location). You are also eligible to receive same or next-day appointments. During the term of this Agreement, the Health Care Services provided by the DPC PRACTICE may be subject to change by the DPC PRACTICE from time to time. Such changes, if any, shall be reflected on the Detailed Service List.
   If you have a pre existing medical condition, please contact us first to leam how you may benefit from DPC PRACTICE'S services.
   Pre existing medical conditions DO NOT disqualify you from enrolling in DPC PRACTICE's service.
   By entering into this Membership Agreement, you acknowledge that DPC PRACTICE does not provide major medical health insurance coverage and that this is not a contract for insurance. DPC PRACTICE provides only the Health Care Services specifically described herein and additional costs may be incurred for laboratory, medical imaging, surgery, specialist care, emergency department visits, and hospitalization required outside of our DPC PRACTICE's services. The DPC Practice encourages you to combine DPC PRACTICE membership with appropriate major medical health insurance coverage.

3. Fees and Payment
   DPC PRACTICE charges the Comprehensive Monthly Fee listed below per Member to include all Covered Healthcare Services included on the Detailed Services List. All invoices are auto drafted on the 15th of every month via electronic ACH payment or credit card. Initial Monthly Fee and Registration Fee is due upon the date of registration.

INDIVIDUAL PLANS A 10% discount will be applied to the total fee for annually pre-paid memberships

• $135/month: Adult Elderly (65+)

• $100/month: Adult (18 - 65)

• $80/month: College Student (18-25) 20% DISCOUNT *** Must provide proof of eligible College Enrollment

FAMILY PLANS

• $300/month:Family Plan (2 Adults + 2 Children)

• $225/month:Family Plan - Single Parents (1 Adult + up to 3 Children)

• $ 85/month:Adult Child (18-26) *** Adult children must be living in the home and/or enrolled in school

• $ 60/month:Child (17 & younger)*** Children must be enrolled in a plan with at least one adult members

ONE TIME REGISTRATION FEES - due with first monthly payment

• Family Plans: $50/person

• Individual Plans: $75

Stonehaven Medical Group

Direct Primary Care (DPC) Practice Membership Agreement

If you request and receive a Non-Covered Health Care Service, you are liable for any charges incurred for the services rendered and the amount is due at the time of service:

Per Texas Occupation Code Chapter 162 Section. 254, DPC Practice is not authorized to submit a claim to be paid by your health insurance plan (or other third party) for a Covered or Non-Covered Health Care Service.

• DPC Practice can submit your insurance for lab work to your health insurance plan.

• If you authorize the DPC PRACTICE to submit a claim to be paid by your health plan or other third party for diagnostic lab services, you hereby authorize DPC PRACTICE to release any information needed to determine benefts payable by a third party or their agents.

• In the event that you receive any payment from a third party for a diagnostic lab services, you agree to tum over the payment in full to the DPC PRACTICES' contracted lab company for services rendered.

• You agree not to submit any claims to any third-party payor or any government health care program for Covered or Non-Covered Services rendered by the DPC PRACTICE to you under this Agreement.

• All Fees paid are non-refundable. This includes all Fees that may have been paid whether such were paid on a monthly or annual basis.

  4. Your Medical Information
  Your privacy is very important to us, and you control the use of your personal information. DPC PRACTICE has put important safeguards in place to make sure your medical information is protected and safe to maintain its confidentiality.
  DPC PRACTICE seeks to work together with you to give you the best health care possible. Having access to your medical information will help your DPC PRACTICE doctor give you the best possible care because he/she will have the most up-to-date information about your health. Therefore, as allowed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and to help us give you the right care, in the right place and at the right time, your health plan and its contractors and agents (Health Pian) may electronically share with us your health-related information (including your "protected health information" as defined by HIPAA). Such shared health-related information may include things like visits to the doctor or hospital, medical conditions, current and past prescriptions, biometric data (height, weight, body fat percentage, etc.) and other health status-related information.

  5. Digital Communications Risks and Conditions
  DPC PRACTICE offers members the ability to send and receive emails and texts to and from their care team. While DPC PRACTICE takes many precautions to protect your information and the security of the emails and texts it sends, there are still risks.

Risks:

Transmitting patient information by email or text has several risks. These risks include but are not limited to the following:

• Email and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.

• Email and text senders can readily misaddress an email or text.

• Email and texts can be intercepted, altered, forwarded, or used without authorization or detection.

• Emails and texts may not be secure, and therefore it is possible that the confidentiality of such communications may be breached by a third party.

• Email and text service providers may have access to your emails and texts.

Conditions:

DPC PRACTICE is not liable for improper disclosure of confidential information that is not caused by DPC PRACTICE's misconduct.

You must acknowledge and consent to the following conditions:

• Email and text are not appropriate, nor should they be used for urgent or emergency situations. Please call 911 in the event of a medical emergency.

• Per your request, DPC PRACTICE may send emails or texts to you as necessary for your diagnosis, treatment, billing, eligibility and other handling. You should not use email or text for sensitive communications (e.g., AIDS/HIV, mental health, developmental disability, or substance abuse).

• You are responsible for informing DPC PRACTICE, in writing, if you want to cease or limit email or text communications with DPC PRACTICE. You may do so at any time without reason or explanation.

• You are responsible for protecting your email account or telephone password or other means of access to your email or text.

  DPC PRACTICE is not liable for breaches of confidentiality involving your email or telephone accounts that are caused by you or any third party.

  By signing this Membership Agreement, you acknowledge that you have received and read the above information. In addition, you agree to any instructions that DPC PRACTICE may impose regarding the sending and receipt of email or text communications containing patient information.

  Recommendations and Instructions:

  If you wish to send and receive emails or texts from DPC PRACTICE regarding your care and treatment, you:

  • Should limit or avoid use of public computers and public networks.

  • Should promptly inform DPC PRACTICE of changes in your email address or telephone number.
    Before sending emails or texts containing personal health information to DPC PRACTICE, you should:

  • Ensure the email or text is addressed to the intended recipient.
    List the key topic in the email subject line.

  • Put your name in the body of the email or text.
    Take precautions to preserve the confidentiality of your emails or texts. Once DPC PRACTICE sends an email or text from its network, it has no control over its confidentiality or security.

  6. Term and Termination

  This Membership Agreement shall begin upon the Effective Date and shall continue for 12 months to the first anniversary date unless it is terminated within 30 days of the effective date by submission of a Membership Cancellation Form. In this case, you will only be charged the registration fee and the first month's Comprehensive Monthly Fee. Patient is not eligible to cancel the membership for a minimum of 6 months from the effective date. If cancellation is requested prior to 6-months, then payment for each month up to 6 months is due before cancellation can be completed. This Agreement will automatically renew on the first anniversary date and all subsequent anniversary dates thereof unless you provide sixty (60) days written notice prior to the anniversary date.

  Notwithstanding the above, to effectively terminate this Membership Agreement, you must complete, sign and submit (via U.S. mail, overnight carrier, email or fax) to DPC PRACTICE a Membership Cancellation Form. Membership Cancellation Forms can be obtained at a DPC PRACTICE clinic or by contacting your DPC PRACTICE. The date of termination shall be the last day of the month in which the Membership Cancellation Form was received and said month in which payment has been received and paid in full.

  An early cancellation fee will be assessed to the patients account upon canceling the membership if cancelled after the 6-month anniversary of effective date.

  The early cancelation fee is equal to one month's Comprehensive Monthly Fee plus the patients

  current Comprehensive Monthly Fee and any outstanding fees associated with the patients' account.

  Cancellation notice and

  balances may include any dependents associated within a Family Plan.

  Should the patient cancel the Family Plan the other adult

  members on the plan may elect to continue with DPC Membership coverage by renewing on an individual plan basis.

  Upon cancellation, after all payments are received for all periods, current, past due balances, and early cancellation fee for the termination of this Membership Agreement, you will not be responsible for any further payments. Any outstanding balances unpaid will be incur interest at a rate of 1.5% per month on any unpaid balance until payment is made in full. Failure to submit payment in a timely manner shall result in the account being forward to a debt collection agency and may impact your consumer credit report.

Stonehaven Medical Group

Direct Primary Care (DPC) Practice Membership Agreement

DPC PRACTICE Detailed Service List

• Covered Healthcare Services
  Annual Wellness Exam Included
  Primary Care Visits Included
  Same Day/Next Day Appointments Included
  Telemedicine Visits (Video Chat) Included
  Well Child Care Visits (3 months +) Included
  Sports Physicals Included

• Covered Healthcare Procedures

  EKG. Included

  Injection Fee (Medication costs may not be covered). Included

  Skin Lesion Excision (first lesion). Included

  Cryotherapy of Warts/skin lesions (0-3 warts). Included

  Yearly Women's Exam Pap Smears. $25

  Ingrown Toenail Removal. $25

  Foreign Body Removal. $50-$250

  Laceration Repair Stitches. $50

  HPV Testing. $20

  Flu Shot.

• Complex Care

  Diabetes Management. Included
  Hypertension Management. Included
  Hyperlipidemia (Cholesterol) Management. Included
  Mental Health/Wellness. Included
  Hospital Admits - Follow-up Appointments. Included
  Weight Management Planning Health & Fitness Management. Included

• Labs & Imaging
  Most in-house lab work. 75% Discount
  Uranalysis Included
  Urine Pregnancy Test. Included
  Rapid Strep Test. Included
  Covid Rapid/Flu Combo Test. $75
  Covid Rapid Test. $50
  Covid Blood Draw Antibody (lab sendoff). Discounted Pricing
  Covid Blood Draw (lab sendoff). Discounted Pricing
  X-Ray.

• Low-Cost meds
  Discount Prescription Card GoodRx Program. Included

• Savings 10% Discount on most Supplemental Products & Services. Included

• Savings 25-75% discount on Non-Covered Healthcare Services. Included

***Payment transactions declined due to insufficient funds or incorrect card information will result in an additional NFT fee of r50 and failure to comply with payment terms may result in termination of the patient's membership. Services will not be rendered for patients with past due accounts until payment is made in full.

Most, but not all, of the services described above in Section 2, are covered by the Comprehensive Monthly Fee, subject to the limitations set forth in this Membership Agreement. However:

Per IRS guidance, if you participate in a high-deductible health plan with a health savings account (HSA) feature, you may be required to pay on a fee-for-service basis for certain primary care, non-preventive care and urgent care services until such time as your deductible has been satisfied. If you don't pay on a fee-for-service basis for these services, it is possible you may lose your ability to contribute to your HSA during your membership. Please consult your attorney or financial adviser.

DPC PRACTICE hereby disclaims any responsibility or liability with respect to your decisions made thereto.

Some Health Care Services provided by DPC PRACTICE are not covered by the Comprehensive Monthly Fee (Non-Covered Health Care Services). The DPC PRACTICE fees for these services will be provided to you upon your request for approval and prior to providing the service. Payment is expected in full at time of service for any patient approved Non-Covered Health Care Service. Invoice for any Non-Covered Health Care Services will be provided to the patient for approval and payment will be processed prior to treatment, unless the DPC PRACTICE has extended a payment plan to the patient. DPC PRACTICE may amend the fee schedule from time to time in its sole and absolute discretion and without prior notice

DPC PRACTICE may terminate this Membership Agreement at any time, subject to any professional obligations without prior notice.

7. DPC PRACTICE Terms

• If any term, provision, covenant or condition of this Membership Agreement is held by a court of competent jurisdiction to be invalid, void or unenforceable, the remaining provisions will remain in full force and effect and will in no way be affected, impaired or invalidated.

• This Membership Agreement will be governed by and construed in accordance with the laws of the state in which the medical office of your DPC PRACTICE physician is located. By signing the Membership Agreement, you agree to have any dispute arising out of the Membership Agreement decided by neutral binding arbitration rather than by a jury or court trial. Any dispute will be submitted to arbitration in the county in the state where you receive services covered by the Membership Agreement. The decision in arbitration shall be conclusive and binding on you and DPC PRACTICE. All arbitration provisions shall be governed by, construed, and enforced with Federal Arbitration Act.

• This Membership Agreement is Non-Transferable.