Created Apr 23, 2023

Last Revised Jun 17, 2024

This is a copy of the enrollment Terms of Service document that is required to acknowledge upon enrolling into the Program.

Table of Contents

• INFORMED CONSENT AGREEMENT FOR WEIGHT LOSS + METABOLIC PROGRAM

• CONSENT FOR TREATMENT IN WEIGHT LOSS + METABOLIC HEALTH PROGRAM

• CONSENT FOR TREATMENT WITH SEMAGLUTIDE OR TIRZEPATIDE PEPTIDE

• PRIME PEPTIDES SPECIFIC ACKNOWLEDGEMENTS FOR ALL PEPTIDE PURCHASERS AND USERS

• GENERAL PEPTIDE THERAPY

• CONSENT TO TELEHEALTH SERVICES

• NOTICE OF PRIVACY PRACTICES AND HIPAA COMPLIANCE

INFORMED CONSENT AGREEMENT

FOR WEIGHT LOSS + METABOLIC PROGRAM

ACTIVE MEMBERSHIP MONTHLY FEE: $299/MONTH*

MAINTENANCE MEMBERSHIP MONTHLY FEE: $79/MONTH

This agreement outlines the terms and conditions of participation in the Weight Loss + Metabolic Program (hereinafter referred to as "the Program") and serves as an informed consent document. By enrolling in the Program, the participant (hereinafter referred to as "the Member") acknowledges and agrees to the following:

PROGRAM DESCRIPTION: The Program fee includes the provision of a medication prescription, patient management, and concierge-level care. The Provider agrees to be available within 24 hours, unless the patient has been given notice in advance, to address any questions or concerns related to their care, including but not limited to side effect management, progress monitoring, and dosing inquiries. It is important to note that the monthly membership fee does not cover the cost of the medication.

The patient is only offered the Maintenance Membership rate of $79/month once the patient reaches their target weight. The Maintenance Membership is specifically designed for patients who have successfully reached their target weight and are now focused on maintaining their health. The concept behind this membership is to provide a level of support that requires minimal provider involvement, given their progress and experience in the program. 

PAYMENT OBLIGATIONS: Failure to make timely payments may result in a delay in care. If two consecutive payments are missed, the Member's membership will be canceled, and they will be unable to rejoin the Program in the future. The Member acknowledges the payment obligations associated with the treatment:

Non-Insurance Coverage: Wellbeing Medical Physician Assistant PC does not accept or bill insurance for this treatment. The Member acknowledges that they are solely responsible for the cost of treatment.

Refund Policy: Once treatment is initiated, refund requests based on scheduling conflicts, missed doses, or unsatisfactory results cannot be honored.

MINIMUM COMMITMENT: The Member is required to commit to a minimum of three months in the Program. Furthermore, rejoining the Program within a six-month timeframe after cancellation is prohibited. A member is only allowed to rejoin twice in their lifetime, unless extenuating circumstances are present and discussed with the Provider, such as pregnancy or illness. If you choose to cancel and rejoin the program, another 3 month minimum will be required. 

CANCELLATION: The Member may cancel their participation in the Program at any time after 3 months by providing written notice via email to the Provider. The Provider reserves the right to cancel a Member's participation or deny treatment if it is deemed medically necessary. Furthermore, it is at the discretion of the Provider to terminate the membership due to concern for Member health, inability to follow protocol or instruction, and/or unrealistic expectations. The Provider may terminate the membership without providing a refund. 

MEMBERSHIP TERMS: This Agreement is personal to the Member and cannot be assigned, transferred, or otherwise disposed of. Applicants must be at least 18 years old to apply. The membership benefits are exclusive to the Member and cannot be utilized by any other individuals (non-transferrable).

TERM AND TERMINATION: Monthly membership options are considered month-to-month agreements and may be canceled by either party with written notice. The membership fee is non-negotiable, non-refundable, non-transferable, and non-cancelable unless otherwise specified herein. The Member must provide written notice of their intent to cancel via email. If a Member cancels, the responsibility for their care will no longer rest with Wellbeing Medical PA PC. The Provider reserves the right to cancel or suspend a membership at any time and for any reason.

FEE AND PAYMENTS: The recurring membership fee, as indicated on the front of this agreement, shall be payable monthly in advance. Membership fees will be charged directly to the Member's credit/debit account.
* Monthly fee $299/month unless special pricing is applied.

SERVICES: Wellbeing Medical PA PC reserves the right to refuse or partially provide any treatment at its sole discretion. By entering into a membership agreement, the Member acknowledges that there is no entitlement or guarantee of receiving any specific treatment, and Wellbeing Medical PA PC does not provide any warranty or guarantee regarding treatment outcomes. Results are not guaranteed or warranted in any way. Wellbeing Medical PA PC retains the right to modify, add, or eliminate services or locations as needed.

MEMBER INFORMATION: The Member must disclose all relevant medical conditions that may impact or be affected by the services provided under this Agreement. It is the Member's responsibility to promptly notify Wellbeing Medical PA PC of any changes in their information, including medical conditions, current address, billing details, or emergency contact.

NO GUARANTEE OR WARRANTY: By signing this waiver, the Member acknowledges that they have read and understood all the terms and conditions, including the benefits and limitations of the Wellbeing Medical PA PC services. The Member certifies that they have disclosed all relevant medical conditions. The Member understands that there is no guarantee for any services provided by Wellbeing Medical PA PC, and this membership agreement does not create an express or implied guarantee or warranty. The Member releases Wellbeing Medical PA PC, its employees, and professionals from any liability arising from any treatment performed or not performed.

ENTIRE AGREEMENT: This Agreement represents the complete terms and conditions of the membership. Any modifications to this Agreement must be made in writing and signed by both Wellbeing Medical PA PC and the Member.

By signing below, I confirm that I have read and understood this Membership Agreement, including the attached terms and conditions, and I agree to be bound by all its provisions. I hereby authorize Wellbeing Medical PA PC to charge my provided credit card in accordance with the terms outlined in this membership agreement, either as a single charge or on a recurring monthly basis. If a monthly membership is selected, I acknowledge that my credit card will be charged on the membership effective date and subsequently on the same day of each month thereafter. I acknowledge that this program is not covered by insurance and that I do not expect any insurance reimbursement. I understand that there are no refunds for any reason.

CONSENT FOR TREATMENT IN WEIGHT LOSS +

METABOLIC HEALTH PROGRAM 

This document serves as an informed consent agreement between the patient (referred to as the "Member") and Wellbeing Medical Physician Assistant PC ("PC") regarding the provision of medical treatment and healthcare services. By requesting and receiving treatment from Wellbeing Medical Physician Assistant PC, the Member acknowledges and agrees to the following:

Treatment Description: The Member acknowledges that they have requested medical treatment and other healthcare services from licensed and certified providers through Wellbeing Medical Physician Assistant PC's telehealth platform. The specific services may include health evaluation and management, health assessments, primary care services, and laboratory panel services. The Member consents to receive these services as deemed necessary and appropriate by the providers.

Right to Decline Treatment: The Member understands that they have the right to decline treatment and services at any time.

Primary Care Provider Follow-up: If the Provider is not the Member's primary care provider, it is the Member's sole responsibility to follow up with their primary care provider regarding any medical conditions or treatments discussed during the assessment and/or treatment provided by the Provider.

CONSENT FOR TREATMENT WITH SEMAGLUTIDE OR TIRZEPATIDE PEPTIDE

I, the Patient, have examined and understood the pertinent information pertaining to the compound known as semaglutide, including its variations as Wegovy, Ozempic, semaglutide combined with or without methylated B12 and/or BPC-157, as well as tirzepatide/Mounjaro, which are components of the weight loss program I have requested from Wellbeings Medical PA PC.

Semaglutide, marketed under the names Ozempic or Wegovy, is an injectable or sublingual medication that, when utilized in conjunction with a low-calorie diet and exercise, assists in the management of chronic weight in adult patients. It is particularly advantageous for individuals with an increased susceptibility to cardiometabolic ailments such as heart attack, stroke, and type 2 diabetes. Semaglutide falls under the category of medications known as glucagon-like peptide-1 (GLP-1) agonists, which replicate the actions of the GLP-1 hormone within the body. The hormone operates by slowing down the rate of gastric emptying, stimulating the release of insulin from the pancreas (thus reducing blood sugar levels), and inhibiting the release of sugar from the liver (glucagon). Collectively, these mechanisms help suppress appetite, leading to reduced food consumption and subsequent weight loss. Semaglutide, similar to other prescription weight-loss medications, is intended to be employed as part of a comprehensive weight-loss plan. It is indicated for individuals who are obese or overweight and have not achieved substantial weight reduction through diet and exercise alone, rather than those seeking to lose only a small amount of weight. 

Tirzepatide, marketed as Mounjaro, is also an injectable medication classified as a twincretin. It functions as both a GLP-1 agonist and a GIP agonist, and shares similar benefits and risks as semaglutide, as mentioned above. However, Mounjaro or tirzepatide is currently exclusively approved by the FDA for the treatment of type 2 diabetes and has not yet received approval for weight loss purposes. 

I acknowledge that the semaglutide and tirzepatide medications I will be utilizing are compounded medications, which may not be identical to the formulations used by Novo Nordisk or Eli Lilly to produce Wegovy or Ozempic. Compounding pharmacies employ FDA-approved ingredients for compounding purposes; nonetheless, the sourcing of these medications by compounding pharmacies cannot be definitively determined, as Novo Nordisk holds the patent for the drug. The ingredients used in compounding are FDA-approved; however, the compounded drugs themselves lack FDA approval and are not subjected to testing or monitoring by the agency.

The Member acknowledges the following regarding the use of semaglutide or tirzepatide for the weight loss program:

Medication Description: Semaglutide, sold under brand names such as Ozempic or Wegovy, is an injectable or sublingual peptide used for chronic weight management in adult patients. Tirzepatide, sold as Mounjaro, is also an injectable peptide with similar benefits and risks. The Member acknowledges that these peptides may have potential benefits for weight loss and cardiometabolic risk factors.

Treatment Alternatives: The Member acknowledges that alternative treatment options include diet and exercise alone, other weight loss prescription medications, or procedure-based weight loss methods such as gastric banding or bypass.

Potential Risks and Side Effects: The Member acknowledges that while semaglutide and tirzepatide are considered safe and effective when used as indicated, there are potential risks and side effects. These may include thyroid C-cell tumors (in rodents), acute pancreatitis, acute gallbladder disease, hypoglycemia, acute kidney injury, diabetic retinopathy, increased heart rate, suicidal behavior, gastroparesis, hospitalizations from dehydration and esophageal bleeding, and potential fetal harm. The Member acknowledges the importance of following the prescribed dosage and dietary restrictions to minimize risks and side effects.

Increased Fertility and Decreased Effectiveness of Oral Contraception:

The Member acknowledges that using semaglutide or tirzepatide can influence their menstrual cycle. Studies have shown that GLP-1 agonists can help regulate ovulation and improve fertility outcomes, especially in women with conditions like polycystic ovary syndrome (PCOS) by enhancing insulin sensitivity and reducing hyperandrogenism​.​​ (Oxford Academic)​. Additionally, due to their effect on delaying gastric emptying, GLP-1 agonists may impact the absorption and decrease the effectiveness of oral contraceptives.

Muscle Mass and Exercise: The Member acknowledges the importance of participating in an exercise routine that includes resistance training alongside the treatment as well as meeting daily protein requirements. It is understood that relying solely on cardio exercises and/or not eating daily protein requirements may lead to the loss of muscle mass in addition to fat mass.

By agreeing to this document, the Member certifies the following:

Age and Understanding: The Member is at least 18 years of age and has received information about semaglutide and tirzepatide.

Health Disclosure: The Member has disclosed and discussed all relevant health conditions or changes in health condition with the Provider.

Agreement to Treatment: The Member wishes to proceed with the recommended course of care involving semaglutide with or without B12 or tirzepatide with or without B12 injections for weight loss, understanding the risks, complications, and side effects associated with the treatment.

Alternatives Considered: The Member acknowledges the alternatives to the proposed treatment and the risks and benefits associated with foregoing treatment altogether.

Benefits and Education: The Member understands the possible benefits of the proposed treatment and has had the opportunity to educate themselves about their health status and the proposed treatment.

Questions and Answers: The Member has had the opportunity to ask questions and has received satisfactory answers in terms they understand.

Reporting Adverse Reactions: The Member agrees to promptly report any adverse reactions or problems experienced after the treatment.

No Guarantee of Specific Benefits: The Member acknowledges that no specific benefits have been promised or guaranteed from the treatment.

Allergies and Medications: The Member has informed the Provider of any known allergies to medications or substances, as well as all current medications and supplements being taken.

Based on the above, the Member knowingly and voluntarily consents to proceed with the proposed treatment and related care. The Member also agrees to comply with the treatment recommendations made by the Provider and to promptly report any complications or adverse changes in health during the treatment.

PRIME PEPTIDES SPECIFIC ACKNOWLEDGEMENTS FOR ALL PEPTIDE PURCHASERS AND USERS

Peptides purchased by the Provider from Prime Peptides, a peptide supplier and laboratory, are developed under Research and Development ("R&D") standards and requirements. While Prime Peptides adheres to FDA-regulated practices, their laboratory is not officially regulated by FDA requirements. The peptides supplied by Prime Peptides are not intended to diagnose, treat, cure, or prevent any disease, and no claims or warranties to that effect are made. You understand and agree that using these products carries significant risks, as they are not FDA authorized or approved for preventing, treating, diagnosing, mitigating, or curing any disease, ailment, or medical condition.

GENERAL PEPTIDE THERAPY 

Introduction
Peptide therapy involves the use of specific peptides to improve various health conditions. Some peptides may be on the FDA bulk substance banned list due to lack of clinical evidence for indication of treatment, dosing guidelines, and safety studies. This consent form outlines the potential benefits, risks, and conditions of using such peptides as part of your treatment plan.

Description of Treatment
Peptides are short chains of amino acids that can help regulate and rejuvenate bodily functions. The peptides used in your treatment may include, but are not limited to:

• Growth hormone-releasing peptides

• Thymosin Beta-4

• BPC-157

• GHK-Cu

• Epitalon

• CJC-1295

Some of these peptides are on the FDA’s bulk substance banned list and are not approved for compounding. 

Potential Benefits

• Enhanced recovery from injuries

• Improved immune function

• Increased muscle mass and strength

• Better skin health

• Improved gut health

• Weight loss and fat reduction

Potential Risks and Side Effects

• Injection site reactions (pain, redness, swelling)

• Allergic reactions

• Hormonal imbalances

• Unanticipated adverse effects due to the investigational nature of the peptides

Patient Responsibilities

• Provide a complete medical history and disclose any current medications or supplements.

• Report any side effects or adverse reactions immediately.

• Follow the prescribed dosage and administration instructions.

• Attend all follow-up appointments for monitoring.

FDA Status and Regulatory Considerations
Some of the peptides used in this therapy are on the FDA bulk substance banned list and are not approved for compounding or specific medical conditions. Their use is considered investigational, and they are not FDA-approved for safety or efficacy. By consenting to this treatment, you acknowledge understanding the regulatory status and potential risks involved.

Informed Consent
By signing this form, you acknowledge that you understand and agree to the following:

1. The nature, benefits, and risks of peptide therapy, including the use of peptides on the FDA bulk substance banned list, have been explained to you.

2. You consent to the use of these peptides as part of your treatment plan.

3. You understand that you can withdraw your consent at any time without affecting your right to future care.

4. You agree to follow the treatment plan and attend all follow-up appointments.

5. You acknowledge that no guarantees have been made regarding the results of peptide therapy.

Patient Consent
I have read and understood the information provided above regarding peptide therapy. I have had the opportunity to ask questions and have received satisfactory answers. I hereby give my informed consent to participate in peptide therapy, including the use of peptides on the FDA bulk substance banned list, with Wellbeings Medical Physician Assistant PC.

CONSENT TO TELEHEALTH SERVICES

Telehealth services involve the delivery of healthcare through electronic communications, information technology, or other means, connecting a healthcare provider and a patient who are not physically present in the same location. Telehealth services may encompass diagnosis, treatment, follow-up, and patient education, utilizing various methods such as electronic transmission of medical records, photo images, personal health information exchange, audio/video/data communications (including messaging or email), utilization of output data from medical devices, and sound/video files. Please be aware that alternative methods of care, including in-person services, may be available, and you retain the right to choose an alternative option at any time. It is advisable to discuss alternative options with your healthcare provider. Furthermore, you acknowledge the requirement to be physically present within the state where the provider is licensed to practice during the consultation.

Anticipated Benefits:

The use of telehealth services may offer the following potential benefits:

• Increased ease and efficiency in accessing medical care, services, and treatment for conditions managed by your healthcare provider(s).

• Ability to receive medical care, services, and treatment from provider(s) at times convenient for you.

• Facilitation of interaction with provider(s) without the necessity of in-person appointments.

Potential Risks:

• While telehealth services provide potential benefits, it is essential to understand and acknowledge the associated potential risks, which include but are not limited to the following:

• Limitations on the quality, accuracy, or effectiveness of the services received from your healthcare provider.

• Possible bugs or errors in technology that could affect functionality, produce incorrect results, render technology unavailable, produce erroneous records/transmissions/data/content, or cause corruption or loss of records/transmissions/data/content.

• Technological failures or limitations that may impede your healthcare provider's ability to accurately diagnose or treat your condition.

• Inability to conduct certain tests or assess vital signs in-person, potentially preventing diagnosis, treatment, or identification of the need for emergency medical care.

• Possible unavailability of treatment for your specific condition, necessitating the pursuit of alternative healthcare or emergency care services.

• Delays in medical evaluation/treatment due to provider unavailability or deficiencies/failures in technology or electronic equipment.

• Risk of breaches in the privacy of your medical or other information due to potential failures in electronic systems, security protocols, or safeguards.

• Increased susceptibility to unintended disclosure of protected health information (PHI) to third parties when electronically stored and communicated, such as through email communications.

• Limitations on your healthcare provider's diagnosis and treatment options, particularly related to certain prescriptions, based on regulatory restrictions within your state or jurisdiction.

• Potential adverse drug interactions or allergic reactions due to limited access to your complete medical records.

Data Privacy and Protection:

The telehealth systems in use incorporate network and software security protocols designed to protect the privacy and security of your information. These systems implement measures to safeguard data against intentional or unintentional corruption. Personal information identifying you or containing PHI will not be disclosed to any third party without your consent unless authorized by law for consultation, treatment, payment/billing, or certain administrative purposes, or as specified in your healthcare provider's Notice of Privacy Practices. Please note that Sameday does not guarantee the security or privacy of the services used for communication, including email service providers.

Disclosure of Provider Information and Patient Grievances:

All healthcare providers affiliated with the Medical Groups possess the necessary licenses, certifications, or permissions to provide healthcare services within the state where such services are rendered. Upon request at the time of treatment, your treating provider's information, including name, highest academic degree, specialty, license status, license number, and board certification (where applicable), will be made available to you as required. Additionally, you retain the right to report concerns or grievances to the appropriate state medical board or other regulatory bodies. The Medical Group will furnish you with information on how to contact relevant regulatory bodies, as mandated by law, and will prominently display this information.

Disclosure of Risks Regarding Specific Services:

By providing your consent, you affirm that you have thoroughly reviewed the following disclosures and have been informed of and comprehend the risks associated with these particular services. Should you have any questions concerning the items or services, it is advisable to discuss them with your treating healthcare provider or primary care physician.

Limitation of Liability:

Under no circumstances shall Wellbeing Medical Physician Assistant PC, Medical Groups, or Labs (collectively referred to as "Companies") be liable to you or any other person or entity for any damages, including incidental and consequential damages, personal injury or wrongful death, lost profits, or damages resulting from lost or corrupted data or business interruption, arising from the use of or inability to use telehealth services ("Services") or any third-party goods and services (including services by Labs or Medical Providers). This applies whether the claim is based on warranty, contract, tort (including negligence), or any other legal theory, even if Companies were advised of the possibility of such damages. The liability of Companies shall be limited to the actual damages incurred by you, not exceeding U.S. $1,000.

Furthermore, Companies shall not be liable for any personal injury, including death, caused by your use, misuse, or inability to use the Services or any third-party goods and services (including services by Labs or Medical Providers). Any claims arising from your use of the Services or any third-party goods and services must be brought within one (1) year from the date of the event giving rise to such action. You understand and agree that your use of any technology, including the Services, and any third-party goods and services related to Companies is contingent upon your waiver of any right to participate in a class action suit against Companies for losses or damages resulting from your use of such technology, Services, or third-party goods and services.

Please be aware that certain jurisdictions may not allow the exclusion of certain warranties or the limitation or exclusion of liability for incidental or consequential damages. To the extent that Companies may not disclaim any implied warranty or limit their liabilities, the scope, duration, and extent of such warranty, as well as the liability of Companies, shall be limited to the minimum extent permitted by applicable law.

NOTICE OF PRIVACY PRACTICES AND HIPAA COMPLIANCE

This document serves as a notification regarding the usage and disclosure of medical information pertaining to you, and outlines your rights to access this information. Please read this notice carefully. Wellbeing Medical Physician Assistant PC ("PC") is legally obligated to protect your Protected Health Information (PHI) and maintain its privacy.

PC is mandated by law to safeguard your PHI, which encompasses any information that can identify you, such as details about your past, present, or future health, medical condition, healthcare provision, or related payments. It is required to provide you with this notice, which explains how, when, and why your PHI will be "used" or "disclosed." The term "use" refers to sharing, examining, utilizing, applying, or analyzing your PHI within PC's practice, while "disclosure" involves releasing, transferring, providing to, or otherwise revealing your PHI to external parties. PC is bound by legal obligations to adhere to the privacy practices detailed in this notice.

However, please note that PC reserves the right to modify the terms of this notice and its privacy policies at any time. Any such changes will apply to PHI already in PC's possession. In the event of substantial policy alterations, PC will promptly revise this notice and make a new copy available upon request.

1. USES AND DISCLOSURES OF YOUR PHI BY PC

PC may utilize and disclose your PHI for various purposes. While some of these uses and disclosures require your prior authorization, others do not. The following categories outline the different types of PC uses and disclosures, along with examples for each category:

A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Without Prior Consent: PC can use and disclose your PHI without your consent for the following reasons:

Treatment: PC can disclose your PHI to licensed healthcare providers, such as physicians, psychiatrists, psychologists, involved in providing you with healthcare services. For instance, if you are receiving treatment from a psychiatrist, PC may disclose your PHI to coordinate your care.

Payment: PC can use and disclose your PHI to bill and collect payment for the treatment and services provided. For example, PC may send your PHI to your insurance company or health plan to obtain payment for healthcare services rendered. PC may also disclose your PHI to business associates such as billing companies or claims processing companies involved in healthcare claims processing.

Health Care Operations: PC can disclose your PHI for operational purposes. This may include evaluating the quality of healthcare services you received or assessing the performance of healthcare professionals involved in your care. PC may also provide your PHI to accountants, attorneys, consultants, and others to ensure compliance with applicable laws.

Other Disclosures: PC may disclose your PHI to others without your consent under specific circumstances, such as when emergency treatment is necessary, or when you are unable to communicate your consent due to incapacitation or severe pain, and it is deemed that you would provide consent if able to do so.

B. Certain Uses and Disclosures Without Consent: PC can use and disclose your PHI without your consent or authorization for the following reasons:

Legal Requirements: When disclosure is mandated by federal, state, or local laws, judicial or administrative proceedings, or law enforcement. For example, PC may disclose information to government agencies and law enforcement personnel as required by law regarding victims of abuse or neglect, or as ordered in a judicial or administrative proceeding.

Public Health Activities: PC may need to report information about you to the county coroner, as required for public health activities.

Health Oversight Activities: PC may provide information to assist government investigations or inspections of healthcare providers or organizations, as required for health oversight activities.

Research Purposes: PC may disclose PHI for medical research purposes, subject to specific circumstances.

Avoiding Harm: In order to prevent or lessen serious harm to individuals, PC may disclose PHI to law enforcement personnel or those capable of preventing such harm.

Government Functions: PC may disclose PHI of military personnel and veterans in certain situations. Additionally, PC may disclose PHI for national security purposes, such as protecting the President or conducting intelligence operations.

Workers' Compensation: PC may provide PHI to comply with workers' compensation laws.

Appointment Reminders and Health-Related Benefits or Services: PC may use PHI to provide appointment reminders or offer information about treatment alternatives, other healthcare services, or benefits.

C. Certain Uses and Disclosures Allowing Objection: PC may disclose your PHI to family, friends, or other individuals involved in your care or payment, unless you object. In emergency situations, consent may be obtained retroactively.

D. Other Uses and Disclosures Requiring Prior Written Authorization: For any situation not covered in Sections III A, B, and C, PC will request your written authorization before using or disclosing your PHI. If you choose to authorize the disclosure of your PHI, you may later revoke this authorization in writing, except if PC has already taken action based on your authorization.

II. YOUR RIGHTS REGARDING YOUR PHI

You have the following rights concerning your PHI:

A. Requesting Limits on Uses and Disclosures: You may ask PC to limit the usage and disclosure of your PHI. While PC will consider your request, it is not legally obligated to accept it. If PC agrees to your request, any limitations will be documented in writing and adhered to, except in emergency situations. However, certain uses and disclosures that PC is legally required or allowed to make cannot be limited.

B. Choosing Alternate Methods of Communication: You have the right to request that PC send information to an alternative address (e.g., work address instead of home address) or through alternate means (e.g., email instead of regular mail). PC must comply with your request as long as it can easily provide the PHI to you in the requested format.

C. Accessing and Obtaining Copies of Your PHI: In most cases, you have the right to review and obtain copies of your PHI held by PC, provided you make a written request. If PC does not possess your PHI but knows where it can be obtained, it will guide you accordingly. PC will respond to your request within 30 days of receipt. In certain situations, PC may deny your request, in which case it will provide a written explanation for the denial and inform you of your right to have the denial reviewed. Instead of providing the requested PHI, PC may offer a summary or explanation of the information, provided you agree to this alternative and the associated costs in advance.

D. Requesting an Accounting of Disclosures: You have the right to receive a list of instances in which PC has disclosed your PHI. This list will exclude uses or disclosures to which you have already consented, such as those made for treatment, payment, or healthcare operations directly to you or your family. The list will also exclude disclosures made for national security purposes, to corrections or law enforcement personnel, or those made before April 15, 2003.

PC will respond to your request for an accounting of disclosures within 60 days and provide the list for the last six years unless you specify a shorter timeframe. The list will include the date of disclosure, the recipient of the PHI (including their known address), a description of the information disclosed, and the reason for the disclosure. PC will provide the list at no cost, but multiple requests within a year may incur reasonable fees.

E. Correcting or Updating Your PHI: If you believe there is an error or omission in your PHI, you have the right to request its correction or amendment by PC. You must submit the request in writing, along with your reasons. PC will respond within 60 days and may deny your request in writing if the PHI is deemed correct, complete, not created by PC, not allowed to be disclosed, or not part of its records. In case of denial, PC will explain the reasons and your right to submit a written statement of disagreement. If you choose not to do so, you can request that your original request and the denial be included with any future disclosures of your PHI. If your request is approved, PC will make the necessary changes, inform you of the update, and notify relevant parties who require the modified PHI.

F. Receiving the Notice by Email: You have the right to receive a copy of this notice by email. However, even if you consent to electronic notice, you retain the right to request a paper copy.

III. FILING A COMPLAINT ABOUT PRIVACY PRACTICES

If you believe that PC has violated your privacy rights or disagree with a decision regarding access to your PHI, you may file a complaint with the designated person listed in Section VI below. Alternatively, you can submit a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C. 20201. PC will not retaliate against you for filing a complaint about its privacy practices.

IV. CONTACT PERSON FOR INFORMATION AND COMPLAINTS

If you have any questions about this notice, complaints about PC's privacy practices, or wish to understand the process for filing a complaint with the Secretary of the Department of Health and Human Services, please contact:

Jessica Brewer

Email: jessica@wellbeingmedical.com

V. EFFECTIVE DATE OF THIS NOTICE

This notice became effective on Apr 24, 2023.