Synergy Premier Patient Intake Form

Welcome to Synergy Premier Access! Thank you for entrusting us with your health care. We
look forward to getting to know you as a person and not just as a patient. Our goal is to
optimize your well-being through a personalized collaborative partnership. To that end, this
Agreement serves to explain how we will work together. By signing this Agreement, remitting
payment for your membership fee, or accepting an in-person or virtual appointment, you agree
to the following terms of this Agreement:

This concierge membership Agreement (“Agreement”) is entered into between the
undersigned (“You,” “Patient,” or “Member”) and Synergy Premier Access (the “Practice,”
“Us,” or “We”). The Practice provides ongoing primary care and personalized medical services
through a hybrid concierge membership model, which combines a periodic membership fee
with the use of health insurance when applicable. In exchange for the membership fees set
forth in this Agreement, the Practice agrees to provide You with the Services described herein
under the terms and conditions contained within this Agreement. Certain medical services may
be billed to insurance or other third-party payors, and the Patient remains responsible for any
amounts not covered by insurance.

1. Services. In this Agreement, “Services” means the collection of services, medical and non-
medical, which are described in Appendix A (attached and incorporated by reference),
which the Practice agrees to provide to You under the terms and conditions of this
Agreement.

2. Patient. In this Agreement, “Patient,” “Member,” "You" or "Yours" means the person for
whom the Practice shall provide care and who has signed this Agreement.

3. Term. This Agreement shall last for one (1) year, starting on the date it is fully executed by
the parties. The Agreement will automatically renew each year on the anniversary date of
the Agreement for successive one (1) year terms. The Patient acknowledges that this
Agreement includes an automatic renewal provision. The Patient may cancel the automatic
renewal at any time by providing written notice to the Practice at least thirty (30) days
prior to the renewal date.

4. Termination.

A. You shall have the right to terminate Your membership at any time without cause
upon thirty (30) days’ written notice to the Practice. Once your written termination
request is received, any prepaid, unused membership fee will be prorated and
refunded.

B. You shall have the right to terminate Your membership immediately upon violation
of the patient-provider relationship or breach of the terms of this Agreement by
Practice.

C. In certain circumstances, it may be necessary for the Practice to terminate Your
membership. In such cases, the Practice will provide you with thirty (30) days’
written notice, or any such other time necessary to transition your care to another
provider.

D. Immediate termination of this Agreement by Practice may be warranted under
certain circumstances including but not limited to:
i. Failure to pay fees and charges when they are due;
ii. Failure to sign required documentation and forms;
iii. Failure to adhere to the recommended treatment plan;
iv. You are disruptive, abusive, or present an emotional of physical danger to the
staff or other patients of the Practice; or
v. The Practice discontinues operation.

5. Payments and Refunds; Amounts and Methods.

A. In exchange for the Services described in Appendix A, You agree to a monthly
payment (“Membership Fee”) in the amount which appears in Appendix B, which is
attached and incorporated herein by reference. The Practice reserves the right to
change its fees at any time with thirty (30) days’ written notice to You. If You do not
consent to the modification, You shall terminate the Agreement in writing prior to
the next scheduled monthly payment.

B. Upon Execution of this Agreement, You shall pay a Monthly Membership fee of $180,
in the amount as described in Appendix B.

C. Thereafter, the Membership Fee shall be due on the first business day of every
month.

D. The Parties agree that the required method of payment shall be by automatic
payment through a debit or credit card that shall be kept on file by the Practice.

6. Participation in Health Insurance. Participation in Health Insurance and Third
Party Payors.

The Practice may participate with certain commercial insurance plans and may submit
claims to third-party payors, including insurance carriers, for covered medical services
provided to the Patient when applicable. The Patient understands that insurance
coverage, benefits, deductibles, copayments, and coinsurance are determined solely by
the Patient’s insurance plan and are not guaranteed by the Practice. The Practice makes
no representations regarding coverage or reimbursement decisions made by any third-
party payor. The Patient acknowledges that insurance may be used for office visits,
diagnostic testing, laboratory services, imaging, or other medically necessary services
when appropriate. The Patient remains financially responsible for any charges not
covered by insurance, including but not limited to deductibles, copayments, coinsurance, non-covered services, or services applied toward a deductible.

The Practice and its providers have not opted out of Medicare. As such, the Practice is
unable to enter into private contracts with Medicare beneficiaries for Medicare-covered
services on a cash-only basis. If the Patient becomes eligible for Medicare during the
term of this Agreement, the Patient agrees to promptly notify the Practice so that
services may be provided in compliance with Medicare regulations.
Membership in Synergy Premier Access is not required for Medicare beneficiaries in
order to receive medically necessary, Medicare-covered services from the Practice. No
Medicare-covered service is conditioned upon enrollment in, or payment of, the
membership fee. Medicare beneficiaries may receive all Medicare-covered services
from the Practice regardless of whether they elect to participate in the Premier Access
membership program.
Patients will not be charged a membership fee for any service for which reimbursement is
sought from Medicare or a commercial health insurance plan.

7. Disclaimer of Insurance / Nature of the Agreement

The Patient acknowledges and understands that this Agreement is not a health insurance plan,
prepaid health plan, or a substitute for comprehensive health insurance coverage. The
membership fee is paid solely in exchange for enhanced access, administrative support, and
care-coordination services that are not reimbursable by Medicare or commercial health
insurance plans.

The membership fee does not include, prepay for, subsidize, offset, or replace any medical
evaluation, diagnosis, treatment, clinical decision-making, or management of medical
conditions.

No Medicare-covered or insurance-covered service is conditioned upon enrollment in, or
payment of, the membership fee. The membership fee does not affect the availability,
scheduling priority, or clinical decision-making related to any medically necessary service,
which is determined solely by medical need and provider judgment.

The Practice strongly encourages all Patients to maintain active health insurance coverage for
services not included in this Agreement, including hospitalizations, emergency services,
specialty care, diagnostic testing, imaging, procedures, and medications.

8. Communications and Privacy.

A. The Practice endeavors to provide You with the convenience of a wide variety of
electronic communication options. Although the Practice is careful to comply
with patient confidentiality requirements and make every attempt to protect your privacy, communications by email, facsimile, video chat, cell phone, texting,
and other electronic means can never be absolutely guaranteed secure or
confidential methods of communications. By signing your name at the end of this
Agreement, You acknowledge the above and indicate that You understand and
agree that by initiating or participating in the above means of communication,
you expressly waive any guarantee of absolute confidentiality with respect to
their use. You further understand that participation in the above means of
communication is not a condition of membership in this Practice and that you
have the option to decline any particular means of communication.

B. Limited Disclosure. The Practice will not disclose Your Protected Health
Information (“PHI”) for reasons unrelated to the delivery of Services, or the
provision of other health care services on Your behalf.

C. Your Privacy Rights. The Practice will adhere to its obligations regarding Your
privacy rights as identified in the Practice’s Patient Notice of Privacy Practices.
Your signature on this Agreement means that You attest that you have read,
understand, and agree to our Patient Notice of Privacy Practices, that You agree
to comply with all policies, consents, terms and conditions regarding Your
responsibilities to the Practice, and that You authorize the Practice to use and
share Your confidential health information with others for treatment, in order to
arrange for payments of Your bill, and for purposes necessary to this Practice’s
heath care operations.

9. Email and Text Usage.
By providing an email address below, You authorize the Practice and its staff to communicate with You by email regarding Your PHI. By providing a cell phone number below and checking the "YES"; box on the corresponding consent question, You consent to text message communication containing PHI through the number provided. You further understand and acknowledge that:

A. Email and text message are not necessarily secure methods of sending or
receiving PHI, and there is always a possibility that a third-party may gain
access; and

B. Email and text messaging are not appropriate means of communication in an
emergency, for dealing with time-sensitive issues, or for disclosing sensitive
information. Therefore, in an emergency or a situation that could reasonably be
expected to develop into an emergency, You agree to call 911 or go to the
nearest emergency care facility and follow the directions of personnel.

10. Technical Failure. Neither the Practice nor its staff will be liable for any loss, injury, or
expense arising from a delay in responding to You when that delay is caused by
technical failure. Examples of technical failures: (i) failures caused by an internet or cell
phone service; (ii) power outages; (iii) failure of electronic messaging software or
email; (iv) failure of the Practice's computers or computer network, or faulty telephone or cable data transmission; (iv) any interception of email communications by a third party which is unauthorized by the Practice; or (v) Patient's failure to comply with the
guidelines for use of email or text messaging, as described in this Agreement.

11. Provider Absence. From time to time, due to such things as vacations, illness, or
personal emergency, the provider may be temporarily unavailable. When the dates of
such absences are known in advance, the Practice shall give notice to Patients so that
they may schedule non-urgent care accordingly. During unexpected absences, Patients
with scheduled appointments shall be notified as soon as practicable, and appointments
shall be rescheduled at the Patient's convenience. If during the provider's absence, You experience an acute medical issue requiring immediate attention, You should proceed to an urgent care or other suitable facility for care. Charges from urgent care or any
other outside provider are not included under this Agreement and are Your
responsibility. You may, however, submit such charges to Your health plan for
reimbursement consideration or request that the outside provider do the same. You are
responsible for understanding the coverage rules of Your health plan, and the Practice
cannot guarantee reimbursement.

12. Dispute Resolution. Each party agrees not to make any inaccurate or untrue and
disparaging statements—oral, written, or electronic—about the other. We strive to
deliver only the best of personalized patient care to every Member, but occasionally
misunderstandings arise. We welcome sincere and open dialogue with our Members,
especially if We fail to meet expectations, and We are committed to resolving all
Member concerns. Therefore, in the event that a Member is dissatisfied with, or has
concerns about, any staff member, service, treatment, or experience arising from their
membership in this Practice, the Member and the Practice agree to refrain from making,
posting or causing to be posted on the internet or any social media, any untrue,
unconfirmed, inaccurate, disparaging comments about the other. Rather, the Parties
agree to engage in the following process:

A. Member shall first discuss any complaints, concerns, or issues with their
provider;

B. The provider shall respond to each of the Member's issues or complaints;

C. If, after such response, Member remains dissatisfied, the Parties shall enter into
discussion and attempt to reach a mutually acceptable solution; and

D. In the unlikely event that we are unable to reach a mutually acceptable solution,
we will continue to work with you to resolve that dispute in good faith, which
may require mediation. If we are unsuccessful, final disposition shall be resolved
by binding arbitration and enforced by any court of competent jurisdiction. The
Practice will choose the provider of arbitration services. Notwithstanding
anything to the contrary, small claims court actions brought by the Practice shall
be exempt from the requirements of this provision.

13. Non-Disparagement. The Patient agrees not to engage in any actions or communications (verbal or written) with any person which would denigrate ordisparage the Practice, or any of its respective officers, directors, agents,
representatives or employees of the Practice, or otherwise adversely affect the
respective business and/or personal reputations of the Practice, or its respective
officers, directors, agents, representatives or employees.

14. Change of Law. If there is a change of any relevant law, regulation or rule, which
affects the terms of this Agreement, the parties agree to amend it only to the extent that
it shall comply with the law.

15. Severability. If any part of this Agreement is considered legally invalid or
unenforceable by a court of competent jurisdiction, that part shall be amended to the
extent necessary to be enforceable, and the remainder of the Agreement will stay in
force as originally written.

16. Amendment. Except as provided within, no amendment of this Agreement shall be
binding on a party unless it is in writing and signed by all the parties.

17. Assignment. Neither this Agreement nor any rights arising under it may be assigned or
transferred without the agreement of the parties.

18. Legal Significance. The Patient acknowledges that this Agreement is a legal document that gives the parties certain rights and responsibilities. The Patient agrees that they are suffering no medical emergency and has had reasonable time to seek legal advice
regarding the Agreement and have either chosen not to do so or have done so and is
satisfied with the terms and conditions of the Agreement.

19. Miscellaneous. This Agreement is to be construed without regard to any rules
requiring that it be construed against the drafting party. The captions in this Agreement
are only for the sake of convenience and have no legal meaning.

20. Entire Agreement. This Agreement contains the entire Agreement between the
parties and replaces any earlier understandings and agreements, whether written or
oral.

21. No Waiver. Either party may choose to delay or not to enforce a right or duty under
this Agreement. Doing so shall not constitute a waiver of that duty or responsibility and
the party shall retain the absolute right to enforce such rights or duties at any time in
the future.
22. Non-Discrimination. Under no circumstances will the Practice discriminate against
You, or terminate this Agreement, on the basis of sex, race, color, religion, ancestry,
national origin, disability, medical condition, genetic information, marital status, sexual
orientation, citizenship, primary language, immigration status, or any other protected
status. However, the Practice reserves the right to accept or decline patients based upon
our capability to appropriately manage the primary care needs of our patients.

23. Governing Law. This Agreement shall be governed and construed under the laws of
the State of Florida without regard to any conflicts of law provisions therein contained.
The parties specifically waive any and all jurisdictional rights under the laws of any
other state. All disputes arising out of this Agreement shall be settled by binding
arbitration. The provider of arbitration services shall be made solely at the Practice’s
discretion and costs of arbitration shall be borne equally by the parties.

24. Notice. Written Notice, when required, may be achieved either through electronic
means at the email address provided by the party to be noticed or through first-class US
Mail. All other required notice must be delivered by first-class US mail to the Practice at:
4122 NW 128 th Terrace, Gainesville, Florida 32606 and to You, at Your address provided
in this Agreement.

25. Survival. Any provisions of this Agreement creating obligations extending beyond the
term of this Agreement shall survive the expiration or termination of this Agreement,
regardless of the reason for such termination.
I understand that no guarantees can be made regarding the outcome of any treatment. I may ask questions or decline treatment at any time.