PLAN OF CARE CONTRACT

The patient hereby acknowledges and understands that all payments for care are made strictly through Upper’s shared billing platform on a cash out-of-pocket (“self-pay”) basis.  The patient understands that he/she should never be billed independently or directly by an in-network provider in order to receive ongoing clinical support and care management by Upper.  All patients must have authorized payment on file, even when receiving financial aid, and are always personally responsible for late cancellations and no-show appointments.

PAYMENT INFORMATION

I hereby authorize Upper to charge my credit card listed below in lieu of presenting it for any rendered goods, services, and/or products upon my request at the time of service.

RELEASE OF LIABILITY

DISCLAIMER: Upper Medicine P.A., Upper Health Inc., and Upper Health Inc. Foundation (collectively referred to as “Upper”) (or any related entity, including but not limited to Upper), is not responsible for any injury (or loss of property) suffered while participating in any services, products, or activities (including supervised appointments of any kind), using equipment, visiting property, or on Upper and any of its affiliates premises, for any reason whatsoever resulting from the ordinary negligence on the part of Upper, its agents, affiliates, partners, providers, contractors, or employees.

WAIVER: In consideration of being permitted to use, today and on all future dates, the services of Upper and its affiliates, I, on behalf of myself, my family, my heirs, personal representatives, and my assigns, do hereby release, waive, discharge, and covenant not to sue Upper its directors, officers, employees, partners, providers, affiliates, contractors, volunteers, and agents from liability from any and all claims arising from the ordinary negligence of Upper Health Inc. or any of the aforementioned parties. This agreement pertains to: 1) personal injury (including death) from accidents or illness arising from participation in Upper services, products, and activities including, but not limited to, organized activities, classes, all recommended and not recommended services, products, partners, and providers, observation, and individual use of Upper’s and its partners facilities, premises, or equipment 2) any and all claims relating to the damage, loss or theft of personal items or property.

ASSUMPTION OF RISK: I acknowledge that I know and understand that Upper does not provide medical services, advice, nor is a medical company. I acknowledge that I know and understand that Upper’s Triage and Concierge Services are basic customer service, not medical advice, and that I am solely responsible for all outcomes of the services that I purchase, engage with, or adhere to regardless of the assistance or advice. I acknowledge that I know, understand, and am respectful of the inherent risks associated with Upper’s health and wellness services and am especially aware of those risks that are prevalent when utilizing provider or partners facilities and equipment and in participating in all forms of activities. At Upper these activities may include, but are not limited to, physician, medical, physical, dietary, mental, and/or alternative medicine services and products such as Concierge Visits, Naturopathic Doctor’s appointments, personal training, yoga, Registered Dietitian consulting, mental health counseling, or acupuncture, and any of the many types of health and wellness services offered. Some of these activities can involve strenuous activity, emotional conversation or triggers, or pain that place stress on my entire physical, environmental, or mental health and well-being. I clearly understand the risks that engaging with any environmental, physical, and mental health services entails, even death. I have and agree to always research the specific risks that my chosen services, products, activities, providers, or businesses entail, I accept the risks, and I understand the nature of the services, products, businesses, providers, partners, and processes at Upper Health Inc. I know the total body and lifestyle demands of the services, products, and activities relative to my total health condition and skill level, and I appreciate the types of injuries and damages which may occur as a result of the activities I choose to take part in with, and affiliated with, Upper Health Inc. By the execution of this agreement, I fully assume responsibility in relation to the inherent risks associated with health and wellness service and product use and assert that I am voluntarily participating in such activities.

INDEMNIFICATION AND HOLD HARMLESS: I further agree to indemnify and save and hold harmless Upper, its employees, contractors, partners, providers, affiliates, agents, and others listed for any and all claims resulting from my own negligence, conduct or participation and to reimburse them for any expense incurred as a result of my involvement with Upper.  Furthermore, I agree to cover all court costs and legal fees incurred by Upper in the investigation and defense of a claim or suit if my claim is dismissed, withdrawn, or a court or arbitrator determines that Upper is not responsible for the injury, illness, death, loss, or damage.

SEVERABILITY AND VENUE: The undersigned also expressly agrees that the foregoing waiver/release of liability agreement is intended to be as broad and inclusive as the State of North Carolina’s laws permit and if that portion thereof is held invalid, it is agreed that the balance of the agreement shall, notwithstanding, continue in full legal force and effect. The undersigned consents to New Hanover County, North Carolina as the exclusive venue for any action or legal proceeding.

ACKNOWLEDGEMENT AND UNDERSTANDING: I acknowledge that I am of legal age and am freely signing this agreement. I acknowledge that I have carefully read this Waiver and Release and fully understand that is a release of liability. By signing below, I am hereby stating my adherence to this agreement and am waiving any right that I may have to bring a legal action to assert a claim against Upper, its directors, officers, employees, volunteers, contractors, partners, providers, related entities and agents for any negligence.

AUTHORIZATION TO ACT ON MY BEHALF

Upper may handle my billing and appointment scheduling on my behalf unless and until revoked by me otherwise in writing. The form that Upper uses to issue my authorization to applicable parties for billing, scheduling, charting, and other care related purposes states,

“To Whom It May Concern,

I have enrolled as a patient with Upper Medicine P.A., managed by Upper Health Inc. (“Upper”).  As part of my enrollment, Upper may verify information contained in my health, payment, and other records and in other documents required in connection with my activity status, such as additional medical and health related memberships, appointments, cancellations, and purchases of any kind pertaining to my health at any point in time while I am an active Upper user.  It is to be assumed that I have been informed of Upper’s actions on my behalf, prior to any action being taken, and after.

I am authorizing Upper to act on my behalf for all purposes related to my care, any memberships, my health records, communication, appointments and scheduling, payments, and in connection with enrollment, as listed throughout this packet.

I hereby authorize Upper to act on my behalf regarding communication, signing, and cancelling contracts, scheduling or appointments, and any payments, refunds, disputes, or financial transactions.  This authorization is valid as of 

(date)____________________________, until cancelled.

This authorization is revocable by me at any time for any reason.”

HIPAA RELEASE FORM

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH OR BILLING INFORMATION

Patient Information: I give permission to release my health information.

Although Upper will use reasonable means to protect the security and confidentiality of emails sent and received, we cannot guarantee the security and confidentiality of all email communications.

I, the undersigned, hereby authorize Upper, its in-network providers, affiliates, agents, and representatives (collectively referred to as “Disclosing Party”), to disclose my protected health information (PHI) and billing information to any healthcare provider or entity within the Upper provider network or involved in my treatment(s), for the purpose of facilitating my healthcare and related billing activities.  Those receiving this may disclose my PHI to Upper.

This authorization includes, but is not limited to, the release of information pertaining to diagnosis, treatment, medications, laboratory results, and any other information relevant to the provision of healthcare services with Upper or my individual plan of care.

I understand that the information disclosed under this authorization may be used for treatment, payment, and healthcare operations, as permitted by the Health Insurance Portability and Accountability Act (HIPAA) and other applicable laws and regulations.

This authorization shall remain in effect throughout the lifetime of my enrollment status, until my patient enrollment status is withdrawn, or unless earlier revoked in writing by me. I understand that I have the right to revoke this authorization at any time, except to the extent that action has been taken in reliance on this authorization.

I acknowledge that the disclosure of my information is voluntary, and I have the right to refuse or limit the scope of this authorization. However, I understand that such refusal or limitation may impact the ability to coordinate and provide comprehensive healthcare services within the Upper provider network.

This authorization is effective as of the date of my signature below.

POLICIES & NOTICES

24-hour Cancellation Policy: I must cancel or reschedule any appointments I need to before 24 hours of the appointment.  If I cancel within the 24 hour window of my appointment that all dues required for that appointment are still due and/or non-refundable.

No Show Policy: Upper has a zero tolerance for no-showing appointments with any in-network provider, and I am responsible for the full cost of my appointment(s) if I no-show and/or am more than five minutes late to any appointment.  If payment has not been made prior to the appointment that was no-showed, I am fully responsible for the balance due of that appointment.

48 Hour & Market Economics Policy: I understand that Upper Health Inc. does not control the costs of the offered care and that independent sellers are solely and independently in control of their prices.  I understand that prices can change day-by-day, including appointments, memberships, diagnostics, products, and more, and that I am subject to new estimates and pricing updates over time with those changes.  I understand that I am fully responsible for the true and most up to date cost of all care congruent with the date of my payment(s).

I understand that due to uncontrollable market conditions and pricing, Upper may provide me with up to 48 hours to make final decisions on care offers before I am automatically subject to new estimates with potential price changes.  I am also then subject to any additional fees to cover the cost of the time to produce the additional estimates, which are due to my own delay in decision making.

Pre-Payment Required: I understand that Upper requires pre-payment for all care purchases (excludes walk-in visits and same-day bookings).

No Refunds: I understand that Upper has a no refund policy, and that any of my unused funds will be applied as a credit to my account for up to one year before expiring.  I may use changed or unused funds on any available care within the Upper health system, even if different from what was originally purchased.

Plans of Care: I understand that Plan of Care payments are required in full or to be paid off within the first five months of my first payment date.I understand that Plan of Care payment plans allow up to five (5) total payments within the first five months are available to me.

I understand that if Upper does not see positive and measured results after six (6) months in my Plan of Care that all of my unused care is fully refundable.

TERMS & CONDITIONS

All charges for rendered care will be due the day of treatment, with 30 day grace periods for delayed payments and payment plan requests.  The patient acknowledges and understands that he/she may be denied additional care or treatments until open invoices for previously rendered services or provided products are paid in full.  You may cancel your active status as a patient in the event that you pay in full any due or unpaid amounts for completed services.

You understand that participating in any wellness, natural, lifestyle, or traditional medical care of any kind made available, sold by, or delivered by Upper, carries risks.

YOU ACKNOWLEDGE AND AGREE THAT THE SOLE RISK OF INJURY OR HARM RESULTING IN ANY MANNER FROM YOUR CHOOSING TO PARTICIPATE IN SUCH REGIMEN, PROGRAMS AND SERVICES BY UPPER OR ITS SELLERS RESTS ENTIRELY WITH YOU TO THE EXTENT THAT YOU DO NOT DISCLOSE YOUR HEALTH CONDITIONS, MEDICATIONS OR DRUG USE TO YOUR PROVIDERS OR SELLERS IN ADVANCE.

You expressly represent and warrant to Upper and its affiliates that you have never been diagnosed with nor treated for any diseases, illnesses or conditions which may result in increased risk when you participate in your voluntarily chosen regimens, programs or services made available by Upper, and you are not choosing to participate with any expectation that Upper, its providers or sellers will screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions.  You acknowledge and understand that Upper is relying upon the foregoing representations and warranties from you upon Upper’s acceptance of you for participation in its memberships, programs, and services.

You acknowledge that Upper and this program is NOT an insurance policy, program, or company of any kind.  You acknowledge no guarantees or assurances have been made to you concerning the results intended from the sessions and programs offered by Upper.  You understand the nature of the sessions and programs and that participating in them carries risks. You have been given an opportunity to ask questions, and all of your questions have been answered fully and to your satisfaction. You agree to your assumption of all risks associated with your participation the sessions and programs and you agree to hold Upper harmless regarding any complications or consequences you experience resulting therefrom.  You acknowledge and accept all of Upper’s website terms of use and conditions.

The present Agreement form is signed today under the rule of present laws and regulations. YOU ACKNOWLEDGE RECEIVING AND READING A COMPLETED COPY OF THIS AGREEMENT BEFORE SIGNING. YOU UNDERSTAND THAT OUR RULES & REGULATATIONS AND THE TERMS IN OUR OVERVIEW BROCHURE ARE INCORPORATED INTO THIS AGREEMENT.

By signing below, I authorize Upper to automatically charge my card on file for my services and products at the time of service.  I understand that Upper may continue to charge my account or cancel my activity status or ability to continue care in accordance with the terms and conditions of this agreement. Additionally, I authorize Upper to charge my credit card on file in lieu of presenting it for any services received, at my request. We agree to sell, and you agree to purchase the goods and services described herein, and in your invoices. You agree to pay us for the goods and services according to your appointment schedule. Your signature below indicates your agreement to be bound to the terms, conditions, rules and regulations of the Agreement. All of terms and conditions in this Agreement, as well as those contained in any Upper materials that have been given to you, are a part of this Agreement. All “Members” signing this Agreement are equally responsible for paying my balances in full.