Concierge Medicine Program Application and Agreement

Welcome to Rebecca Sinai, D.O. Concierge Medicine Program. This document serves as your formal enrollment application and agreement, outlining the personalized healthcare services, membership terms, and clinical commitments provided by our practice. Please review the following sections carefully to complete your enrollment.

Rebecca Sinai, D.O. Concierge Medicine Program Enrollment Application and Agreement

The undersigned hereby applies for enrollment in the Rebecca Sinai, D.O. Concierge Medicine Program. If this application is accepted, the undersigned will become a member of the Rebecca Sinai, D.O. Concierge Medicine Program effective as of the date of the initial payment for participation and under the provisions set forth below and contained in the Concierge Program Terms and Conditions, which together constitute the “Agreement” between the undersigned and Rebecca Sinai, D.O. Concierge Medicine.

Term and Payment Option

Patients choose one of the following two options at enrollment:

• Monthly Payment Option - Monthly Membership Fee: $175
• Annual Payment Option - Annual Membership Fee: $1,800

Note: Both the Monthly Payment Option and the Annual Payment Option constitute a 12-month commitment. The only difference between the two alternatives is that payments under the Monthly Payment Option are on a monthly basis for 12 months and not once annually.

Payment Method

Patients may pay using any of the following methods:

• Debit Card or Cash
• Check - made payable to “Rebecca Sinai, D.O. Concierge Medicine”
• Credit Card - to be furnished telephonically or in person by Patient to Rebecca Sinai, D.O. Concierge Medicine Program
• Other payment methods by arrangement with the office

1. Principal Physician

Patient designates Rebecca S. Sinai, D.O. (the “Principal Physician”) to render professional medical care services to Patient in accordance with this Agreement. Patient understands and acknowledges that Principal Physician may not be available from time to time and may designate a physician or other licensed medical professional (the “Covering Physician”) to attend to Patient’s medical care needs on a temporary basis during Principal Physician’s unavailability. Patient further acknowledges, and consents that Covering Physician will be allowed access to Patient’s medical history and course of care to better facilitate Patient’s medical care needs during Principal Physician’s unavailability.

2. Concierge Program Services

During weekends, nights, and other periods when Rebecca Sinai, D.O. Concierge Medicine’s offices are closed, Patient will, as an enrollee in the Concierge Program, be furnished with the telephone number to contact Principal Physician or, in Principal Physician’s absence, such other designee of Rebecca Sinai, D.O. Concierge Medicine. Notwithstanding the foregoing, in the event that Patient is experiencing a medical emergency, Patient is to immediately contact 911.

In addition, Rebecca Sinai, D.O. Concierge Medicine will make commercially reasonable efforts to: during normal business hours, cause telephone calls to be answered by Rebecca Sinai, D.O. Concierge Medicine staff members on a dedicated telephone line (i.e., no answering services or automated phone menus); furnish Patient with 24-hour emergency access to Principal Physician or Covering Physician, subject to Patient’s understanding that 911 should be contacted if Patient is experiencing a medical emergency, as discussed in Section 6(e) below; furnish to Patient same or next business day appointments for select non-urgent care; cause all Patient existing non-emergency prescription renewals that do not require prior authorization to be processed within one (1) business day (provided that Patient is compliant with follow-up appointments and appropriate lab work has been completed); furnish to Patient longer appointment durations (i.e., as compared to customary norms in the medical marketplace) to more fully learn and listen to Patient’s health concerns; and if Patient arrives on a timely basis, ensure that Patient shall have minimal to no wait time upon arrival.

All of the foregoing services provided for in this Section 2 shall constitute the “Services”; provided, however, that notwithstanding anything to the contrary, regardless of whether or not Patient is a Medicare beneficiary, in no event shall any of the Services be deemed to include any services to which any Medicare beneficiary is from time to time entitled to.

3. Membership Fee

The Patient will pay the participation fee associated with the Concierge Program Membership Option selected by Patient in the Application (the “Membership Fee”) to Rebecca Sinai, D.O. Concierge Medicine to participate in the Concierge Program and to receive the Services enumerated in Paragraph 2 of these Terms and Conditions. Rebecca Sinai, D.O. Concierge Medicine reserves the right to periodically adjust the Membership Fee in any annual renewal.

4. Payment

In the Application portion of this Agreement, Patient has selected either the Annual Payment Option or the Monthly Payment Option. For the Annual Payment Option, Patient shall pay the applicable Annual Membership Fee upon mutual execution of the Application portion of this Agreement. For the Monthly Payment Option: (i) if the Commencement Date occurs on the first day of a calendar month, Patient shall pay three (3) months of the applicable Monthly Membership Fee on the Commencement Date; provided, however, that if the Commencement Date is any day other than the first day of a calendar month, Patient shall, on the Commencement Date, pay a prorated portion of the applicable Monthly Membership Fee for the remaining days in the initial calendar month of enrollment, plus two (2) full months’ Monthly Membership Fee; and thereafter (ii) Patient shall pay the applicable Monthly Membership Fee on the first day of the third calendar month after the month of the Commencement Date (e.g., May 1st if the Commencement Date occurred on any day during February), and on the first day of each of the eight ensuing calendar months.

All scheduled payments must be made punctually, time being of the essence thereof. All fees shall be paid in full via check (preferred method) or debit card, cash, or credit card (all major credit cards accepted). Checks are to be made out to Rebecca Sinai, D.O. Concierge Medicine and mailed to 7455 W. Washington Ave., Suite 200, Las Vegas, Nevada 89128.

5. Term

The term (“Term”) of Patient’s enrollment in the Concierge Program, regardless of the Patient’s selection of payment options, shall start on the Commencement Date and continue for a period of one (1) year, and if Patient does not punctually pay the renewal Membership Fee then in effect and as from time to time determined by Rebecca Sinai, D.O. Concierge Medicine prior to the completion of the Term (as from time to time extended), Patient’s participation in the Concierge Program will be terminated at the completion of the Term, which is the anniversary of the Commencement Date.

Subject to the payment obligations set forth below, either Patient or Rebecca Sinai, D.O. Concierge Medicine may terminate this Agreement, and the physician-patient relationship at Rebecca Sinai, D.O. Concierge Medicine, by providing the other party with thirty (30) days’ prior written notice; provided, however, that notwithstanding any termination as set forth above or anything else to the contrary: (i) for patients enrolled under the Monthly Payment Option, termination by Patient shall be effective as of the last day of the Term then in effect and Patient shall in all events continue to be obligated to punctually pay all Monthly Membership Fees; and (ii) all Membership Fee payments in respect of the Term of such termination (including any Monthly Membership Fees accruing after any such termination but during the Term), are earned upon enrollment and/or continued enrollment (as applicable) in the Concierge Program, and are in all events non-refundable.

6. Medical Care Services that are not a Part of the Concierge Program Services

Only the Services enumerated in Paragraph 2 of these Terms and Conditions are furnished under the Concierge Program and paid for through the Membership Fee. Except for those Services described herein, the Patient and/or the Patient’s insurer, as the case may be, will be financially responsible for paying for all healthcare and medical care services received by the Patient from Rebecca Sinai, D.O. Concierge Medicine and/or Principal Physician. Rebecca Sinai, D.O. Concierge Medicine will bill the Patient and/or the Patient’s insurer, as the case may be, for those healthcare or medical services provided to the Patient. Patients who do not carry insurance will be billed and must pay for any services furnished by Rebecca Sinai, D.O. Concierge Medicine that are not a part of the Services conferred hereunder as part of the Concierge Program, and the charges for such Services shall be at Rebecca Sinai, D.O. Concierge Medicine’s regular rates therefore.

For the avoidance of doubt, the Services furnished under the Concierge Program and paid for through the Membership Fee do not cover those services that Medicare or the Patient’s health insurance pays for, including, without limitation, any Medicare- or insurance-mandated initial or annual physical examinations. Without limitation, Patient acknowledges that:

• Rebecca Sinai, D.O. Concierge Medicine, Principal Physician, and Covering Physician do not provide inpatient care and will not admit, treat, or follow Patient at any hospital should Patient need. Rebecca Sinai, D.O. Concierge Medicine will, at Patient’s request and with Patient’s consent, communicate and coordinate care with other providers of Patient’s;
• To the extent that Patient requires medical care not covered by this Agreement, Rebecca Sinai, D.O. Concierge Medicine will refer Patient to another healthcare provider and/or assist Patient in finding a provider, and will help coordinate and ensure appropriate transfer of care, including providing copies of any relevant medical records;
• Rebecca Sinai, D.O. Concierge Medicine, Principal Physician, and any Covering Physician may at any time and from time to time, in their sole discretion, restrict prescribing and/or discontinue issuing prescriptions for controlled substances for Patient, and accordingly, if Patient should require long-term, chronic pain management, Patient may be referred to a specialist provider to treat chronic pain and/or Rebecca Sinai, D.O. Concierge Medicine may assist Patient in transferring care and treatment to the provider of Patient’s choice;
• The patient will inform Rebecca Sinai, D.O. Concierge Medicine of all controlled substances that are prescribed to Patient by any other provider and acknowledges that this is an on-going obligation on Patient’s part as a Patient of the Concierge Program;
• The Services rendered under this Agreement are not intended to be a substitute for emergency care; accordingly, if Patient believes Patient needs emergency care or treatment, Patient will always seek care from Patient’s local hospital and/or call 911 for emergency medical services; and
• This Agreement is not an insurance plan and is not a substitute for a health insurance plan or health insurance coverage, so Patient is responsible for costs including, without limitation, for copays, deductibles, co-insurances, and other payments for office visits, referral/specialist office visits (it being acknowledged by patient that office visits have been billed at $75 each but that such amount may from time to time be increased at the discretion of Rebecca Sinai, D.O. Concierge Medicine), third party costs, laboratory testing, radiology studies, and procedures outlined in Patient’s insurance policy, and the annual Concierge Program Membership Fee is separate from those medical services provided.

7. Limited Participation in Insurance

Patient acknowledges that Rebecca Sinai, D.O. Concierge Medicine participates in a limited number of health insurance plans. It is the Patient’s responsibility to determine whether Rebecca Sinai, D.O. Concierge Medicine participates in the Patient’s health insurance plan.

8. Co-Payment

The Membership Fee does not affect the co-payments, co-insurance or deductibles that the Patient is required to pay pursuant to the terms of his or her insurance coverage. The Patient will continue to be financially responsible for any co-payments, coinsurance or deductible amounts required by his or her insurer. If Patient is not covered by a health insurance plan or network, Rebecca Sinai, D.O. Concierge Medicine will provide Patient a schedule of all charges for all medical visits, testing and services costs provided by Rebecca Sinai, D.O. Concierge Medicine and/or Principal Physician (except those Services described in Paragraph 2 above), and Patient agrees to promptly pay all such charges.

9. Electronic Communications

Patient understands that traditional e-mail and texting is not a secure medium for sending or receiving potentially sensitive personal health information. Patient further acknowledges that e-mail and/or texting in any form is not an appropriate medium for urgent or time sensitive communications, and accordingly all urgent or time sensitive communications from Patient to Rebecca Sinai, D.O. Concierge Medicine will be made by telephone or in person.

10. Consent of Treatment

Patient authorizes and consents to Rebecca Sinai, D.O. Concierge Medicine’s treatment and procedures, and acknowledges that no guarantee or assurance has been made as to the outcome of such treatment and procedures.

11. Complications

Patient understands that it is his or her responsibility to contact Rebecca Sinai, D.O. Concierge Medicine to report any complications and/or changes in condition.

12. Consents

Patient agrees to complete and execute such consent forms (each, a “Consent Form”) in such forms as Rebecca Sinai, D.O. Concierge Medicine may from time to time designate.

13. Notices

Any notice under this Agreement shall be delivered personally or by US Mail, registered/return receipt requested. Any notice under this Agreement may be delivered to Rebecca Sinai, D.O. Concierge Medicine at 7455 W. Washington Ave., Suite 200, Las Vegas, Nevada 89128 and any notice under this Agreement required to be provided to Patient will be delivered to the most recent address in the Patient medical file.

14. Governing Law; Dispute Resolution; Costs and Fees; WAIVER OF JURY TRIAL

This Agreement shall be governed by and construed in accordance with the laws of the State of Nevada, without regard to its principles of conflict of laws. Any controversy or claim arising out of or relating to this Agreement, or the breach thereof, shall be settled by binding and final confidential arbitration proceedings conducted in Clark County, Nevada by the American Health Lawyers Association in accordance with its rules. Judgment upon the award rendered by the arbitrator may be entered in any court of competent jurisdiction. The parties agree that the court or arbitrator may award reasonable costs and attorneys’ fees to the prevailing party.

The parties to this Agreement desire to avoid the additional time and expense related to a jury trial of any claims or disputes arising hereunder or relating or connected in any manner to this Agreement, in the event that the arbitration provision in this Section is inapplicable or is declared by a court of law to be unenforceable for any reason.

Therefore, it is mutually agreed by and between the parties hereto, and for their successors and assigns, that they shall and hereby do waive trial by jury of any claim or dispute, including any counterclaims, or third-party claims, brought by either party against the other arising out of or in any way connected with this agreement and the relationship which arises herefrom. The parties acknowledge and agree that this waiver is knowingly, freely, and voluntarily given, is desired by all parties, and is in the best interests of all parties.

15. Regulatory Compliance

It is the intent of the parties that this Agreement comply in all respects with all applicable federal, state, and local laws, rules, regulations, and interpretive case decisions, and the parties have structured their relationship with that specific intent. However, each party understands that such laws, rules, regulations, and case law are complicated and periodically in a state of flux. Therefore, in the event that any provision of this Agreement is rendered invalid or unenforceable by a court of competent jurisdiction, or the applicable laws and regulations are altered by any legislative or regulatory body, or either party notifies the other party in writing of its reasonable belief that this Agreement or any of its provisions may be declared null, void, unenforceable, or in violation of applicable laws or regulations, and such party is in fact correct as to such conclusion, the remaining provisions, if any, of this Agreement shall nevertheless continue in full force and effect; provided, however, that thereupon either party may without prior notice terminate the Agreement, except to the extent that such modification to the Agreement would be made as a result of one party’s assertion of its reasonable belief, in which event only the other such party shall have such right of termination.

16. Assignment

Neither this Agreement, nor any rights Patient may have under it, may be assigned or transferred by Patient to any other individual, any such attempt to assign or transfer this Agreement shall be considered null and void. The rights and obligations of Rebecca Sinai, D.O. Concierge Medicine under this Agreement may be assigned by Rebecca Sinai, D.O. Concierge Medicine and shall inure to the benefit of and be enforceable by the successors and assigns of Rebecca Sinai, D.O. Concierge Medicine.

17. Miscellaneous

This Agreement constitutes the sole and entire agreement between Rebecca Sinai, D.O. Concierge Medicine and Patient with respect to the Concierge Program and may only be amended by written agreement executed by both parties. Any prior agreements, promises, negotiations, or representations, either oral or written, relating to the subject matter of this Agreement not expressly set forth in this Agreement are of no force or effect. The waiver by either party of a breach or violation of any provision of this Agreement shall not operate as or be construed to be a continuing waiver or a waiver of any subsequent breach of either the same or any other provision of this Agreement. This Agreement may be executed in a number of counterparts, each of which executed counterparts shall be deemed an original, and all such counterparts together shall constitute one and the same instrument.

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