Healthcare Subscription Agreement

HEALTHCARE SUBSCRIPTION AGREEMENT

This Healthcare Subscription Agreement (the Agreement) is entered into as of Enrollment Date: by and between Provider Name: and Subscriber Name: . Provider agrees to make available, and Subscriber agrees to subscribe to, the healthcare services described herein under the terms and conditions set forth below.

1. Definitions and Scope of Services

Services means the professional healthcare and subscription services described in Service Description. Service Description:

2. Term; Renewal; Termination

The initial term of this Agreement begins on the Enrollment Date and continues for Term Length (months): unless earlier terminated in accordance with this Agreement. This Agreement automatically renews for successive renewal terms of the same duration unless either party provides written notice of non-renewal at least Notice Period (days): prior to the end of the then-current term.

Either party may terminate for material breach following thirty (30) days written notice and failure to cure unless immediate termination is required to protect patient safety or comply with law.

3. Fees, Billing and Payment Authorization

Payment Method (select all that apply):

Credit Card    ACH / Bank Transfer    Insurance Assignment

By signing this Agreement Subscriber authorizes Provider to charge Subscriber for all fees and applicable taxes, including automatic renewal charges. Subscriber agrees that any returned payment may incur a service fee and that Provider may suspend Services for unpaid balances.

4. Enrollment and Eligibility

Subscriber represents and warrants that Subscriber is eligible to receive the Services and that all information provided in the Patient Information and Insurance Information sections is true and complete. Provider may refuse or suspend Services if Subscriber ceases to meet eligibility criteria.

5. Patient Information

Male    Female    Other / Prefer not to say

6. Insurance Information

7. Medical History and Current Health Information

8. Consent to Treatment; Acknowledgements

Subscriber hereby consents to the provision of Services by Provider and its licensed clinicians. Subscriber acknowledges that there are risks and benefits associated with medical care and telehealth, and Subscriber has the opportunity to ask questions and decline particular services. Subscriber understands that participation is voluntary and that Subscriber may withdraw consent at any time by providing written notice.

Subscriber confirms the accuracy of the medical information provided and agrees to promptly notify Provider of any material changes to health status or medications.

9. Privacy, HIPAA and Authorization to Use/Disclose Protected Health Information

Subscriber acknowledges receipt of Provider's Notice of Privacy Practices and authorizes Provider to use and disclose Subscriber's protected health information as reasonably necessary to provide Services, process claims, coordinate care, and as required by law. This authorization includes exchange of information with payors, consulting clinicians, and pharmacies where necessary for treatment and payment.

Subscriber may revoke this authorization in writing except to the extent that Provider has already relied on the authorization. Revocation does not affect disclosures made prior to receipt of revocation.

10. Limitation of Liability; Indemnification

To the fullest extent permitted by law, Provider's liability arising from or related to this Agreement or the Services shall be limited to direct damages not to exceed the total fees paid by Subscriber to Provider in the twelve (12) months preceding the event giving rise to the claim. IN NO EVENT SHALL PROVIDER BE LIABLE FOR INDIRECT, INCIDENTAL, SPECIAL OR CONSEQUENTIAL DAMAGES.

Subscriber agrees to indemnify, defend and hold harmless Provider and its affiliates, officers, employees and agents from and against any third-party claims, liabilities, losses or expenses arising out of Subscriber's breach of this Agreement or negligent acts or omissions.

11. Assignment; Governing Law; Dispute Resolution

Provider may assign its rights and obligations under this Agreement in connection with a sale, merger or transfer of Provider's business. Subscriber may not assign this Agreement without Provider's prior written consent.

Any dispute arising under this Agreement shall first be submitted to good faith negotiations. If unresolved, disputes shall be resolved by binding arbitration in the agreed governing jurisdiction, except where prohibited by law.

12. Notices

Notices under this Agreement shall be in writing and delivered to the addresses provided below.

13. Miscellaneous

This Agreement constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior negotiations and agreements. Any amendment must be in writing and signed by both parties. If any provision is held invalid, the remainder shall remain in full force.

14. Certification and Acknowledgment

By signing below, Subscriber and Provider each certify that they have full authority to enter into this Agreement, that they have read and understand its terms, and that the information provided herein is true and correct to the best of their knowledge.

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