FIRSTCHOICE FAMILY MEDICINE

PRIVATE PRACTICE-PATIENT AGREEMENT

This Private Practice-Patient Agreement (“Agreement”) specifies the terms and conditions under which, you, the undersigned patient (“Patient”) may participate in certain private direct health programs identified in the attached Schedule A (“Services”) offered by Thy Nguyen MD LLC d/b/a FirstChoice Family Medicine (“Practice”).  (Patient and Practice are referred to individually as “Party” or collectively as “Parties”).

SUBSCRIPTION MEDICAL PRACTICE EXPLAINED

Practice’s Services include voluntary subscription offerings that Patient subscribes to in exchange for Patient paying private fees directly to Practice.  These Services exceed or are beyond those covered by Patient’s Medicare, Medicaid or private insurance plan (“Plan”).

SERVICES AND BENEFITS

In exchange for the subscription, Program Fees (defined below), Practice will make available to Patient the Services outlined in Schedule A.  Practice reserves the right to update the schedule of Services from time to time, and if it does, it will notify Patient of any changes within thirty (30) days after a change is made and secure Patient’s voluntary consent to any such modification of Services.

PROGRAM FEES

For the Services, the subscribing Patient will pay voluntary subscription fees (“Program Fees”) for the programs selected by Patient from the Services offerings in Schedule A.  The Program Fees cover the program Services selected by Patient for a period of twelve (12) months from the date Patient signs this Agreement, and may be payable on a quarterly, biannual or annual basis.  The Program Fees may increase from time to time with the voluntary consent in advance by Patient, but will apply to renewal terms.  In the event of Program Fees increases, Patient will receive notification in writing and the option of consenting to such increase.

PAYMENT OPTIONS

The Program Fees can be paid with either a check or credit card. Please make checks payable to:  Thy Nguyen MD LLC.  If Patient is choosing the quarterly or biannual payment option and does not make the initial payment with a check, please submit a voided check so that automatic (“ACH”) withdrawals can be set up.  If Patient is paying quarterly or bi annually, the ACH withdrawal will be established for the next payment to be withdrawn by the 1^st or the 15^th of the respected month due.

RENEWALS AND TERMINATION

The Program Fees cover the availability of the Services selected by and subscribed to by Patient for a period of one (1) year.  Patient will be automatically renewed for enrollment into Practice each year unless Practice receives written notice from Patient of withdrawal from Practice thirty (30) days prior to Patient’s renewal date.  Failure to pay the renewal Program Fees before the expiration of the prior period may result in termination of enrollment in Practice.  Practice is permitted to terminate this Agreement with thirty (30) days’ prior written notice, in which case, Patient will receive a prorated refund of the Program Fees.  Patient is permitted to terminate this Agreement with thirty (30) days’ written notice which includes Patient’s reason for termination, in order to receive to a prorated refund of any unused Program Fees.

HEALTH CARE SERVICES THAT ARE EXCLUDED FROM ANNUAL PRACTICE FEE

The Program Fees cover only the Services subscribed to by Patient.  If Practice provides services other than the Services listed in Schedule A, Patient and Practice may mutually agree upon any additional charges, if any, to the extent the Patient’s Plan does not cover those services.  Patient acknowledges that either Patient or Patient’s Plan will be responsible for these additional charges.  Any charges to Patient for any services outside of Plan coverage will be at our usual, reasonable and customary rates and consented to in advance by Patient before any such charge is incurred.

EMAIL COMMUNICATION

If Patient wishes to communicate through email with Practice, Patient must be aware that email is not a secure medium for sending or receiving sensitive personal health information.  Practice will take steps to keep Patient’s communications confidential and secure.  Patient acknowledges and understands that email is not a good medium for urgent or time-sensitive communications. In the event the communication is time sensitive, Patient must communicate with Practice by telephone or in person.  Please refer to the separate Electronic Communications Agreement for further applicable details in this regard, which is integrated herein by this reference.

APPOINTMENTS AND SCHEDULING

Appointments with Practice are scheduled through Practice office to ensure ample time is given to each Patient.  If Patient has an urgent concern, Patient shall call Practice office and Patient will be given an appointment that will accommodate the urgency.  The Practice patient schedule is organized in such a way that it provides and protects extensive time for each Patient. Walk-ins are not conducive to the thoughtfully planned schedule, so Practice advises Patient to call for any needs that require Patient to have time with Practice physician.

MEDICARE

If Patient is or becomes Medicare eligible, Patient acknowledges that Practice is a participating Medicare provide and pursuant to applicable federal regulations Practice will submit reimbursement claims to Medicare for all Medicare-covered services provided to Patient by Practice.  Patient shall not submit to Medicare any claim for payment of Program Fees or request that Practice submit such a claim.  Patient acknowledges and understands that Medicare will not pay for the Services referenced in Schedule A.

VACATIONS AND ILLNESS FOR PRACTICE PHYSICIANS

Patient acknowledges that there may be times that Patient cannot contact a Practice physician due to the physician’s vacations or illness, or due to technical defects with either Patient’s or Practice’s electronic communication equipment.  Patient acknowledges that, should a Practice physician become unavailable, Practice shall make every effort to give advance notice to Patient so that Services can be scheduled on another date. In cases of emergency, contact information for a covering physician provider will be offered.

COMPLIANCE WITH LAW

In establishing the 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.  If there is a change of any law, regulation or rule, federal, state or local, which affects the Agreement or the activities of either Party under the Agreement, or any change in judicial or administrative interpretation of any such law, regulation or rule, this Agreement shall be deemed modified so as to remain in compliance with such laws.

PRACTICE IS NOT AN INSURER

Practice is not an insurance company and is not promising unlimited care for the Program Fees.  Practice presumes that Patient is either eligible for Medicare, or otherwise has a private Plan that provides health care coverage for essential healthcare services not covered by Practice Fee.

AGREEMENT ASSIGNMENT And MODIFICATIONS

This Agreement may not be assigned to any other person by Patient.  This Agreement replaces and supersedes all prior agreements between Patient and Practice.  This Agreement may not be modified absent a writing signed by Patient and an authorized representative of Practice.

PATIENT ACKNOWLEDGES THAT HE/SHE HAS CAREFULLY READ THIS AGREEMENT, WAS AFFORDED SUFFICIENT OPPORTUNITY TO CONSULT WITH LEGAL COUNSEL OF HIS/HER CHOICE AND TO ASK QUESTIONS AND RECEIVE SATISFACTORY ANSWERS REGARDING THIS AGREEMENT, UNDERSTAND HIS/HER RESPECTIVE RIGHTS AND OBLIGATIONS UNDER IT, AND SIGNED IT OF HIS/HER OWN FREE WILL AND VOLITION.

SCHEDULE A

1.     “360 Degree” Annual Routine Examination

Practice will provide Patient with a “360 Degree” comprehensive annual diagnostic physical examination that is delivered regardless of medical necessity or condition (“Annual Exam”) to take a complete and thorough evaluation of your health status and identify health conditions requiring care, and to create a baseline of health information and health-related goals to assist Practice with providing Patient annual health goal support and education.

The Annual Exam will integrate lifestyle, nutrition, fitness, and other related information provided by Patient, and create specific health goals for the year based on the Annual Exam.

Annual Exam Fee: $360.00/year

2. Health Data Communications & Storage Subscription Plan

Practice will provide Patient subscription access to Practice’s online health data storage and communication facilitation platform plan, which will allow and empower Patient to interact with Practice via electronic communication regarding Annual Exam health data-based guidance, education and support (“Health Data Plan”). Health Data Plan services include ongoing electronic communication exchanges with Patient to secure Annual Exam-related health data updates, to provide related health education and support.

Health Data Plan Fee: $100.00/month (Founder’s rate)  $125.00/month (New Patient rate)

3. Lifestyle Support Plan

Practice will provide Patients who subscribe to the Annual Exam and Health Data Plan an additional level of service that includes monthly check-ins with food shopping and specific lifestyle and fitness goal tracking, additional health and wellness education beyond the Annual Exam guidance that integrates Patient’s own health data tracking (such as Fitbit, MyFitnessPal, Apple health kit data) with ongoing behavior change tracking. The Lifestyle Support Plan is to provide an even more robust connection to the Practice, well beyond the typical concierge or DPC primary care practice, to achieve a high level of lifestyle/health coaching toward specific lifestyle and health goals. Lifestyle Support services include Annual Exam-based weight management, fitness and lifestyle goal setting and ongoing guidance via electronic communication exchanges.

Lifestyle Support Plan Fee: $50.00/month

4. Elective Cosmetic/Wellness Services

Practice offers Patient the opportunity to utilize the benefits of Contoura radio frequency treatment that targets and reduces fat cells while also tightening the skin. While Patient’s dietary intake and fitness level ultimately determines the Patient’s overall body fat percentage, with the majority of impact caused by dietary intake, the fat destruction treatment can provide helpful support towards Patient’s body image and fat percentage goals by destroying fat cells and tightening skin. This radio frequency treatment can be applied to underneath the chin, along the bra line, in the abdomen, thighs, knees, arms, and other areas of the body. Practice also offers Botox and Juvederm treatments to decrease signs of aging.

See Practice updated price charts for all cosmetic procedure prices.