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     This Azumaya Health Patient Agreement (“Agreement”) specifies the terms and conditions under which, you, the undersigned patient (“Patient”) may participate in certain private direct health services identified in the attached Schedule A (“Services”) offered by Azumaya Health (“Practice”). (Patient and Practice are referred to individually as “Party” or collectively as “Parties”).

SUBSCRIPTION MEDICAL PRACTICE EXPLAINED The Practice’s Services include voluntary subscription offerings that Patient subscribes to in exchange for Patient paying private fees directly to Practice. These Services exceed or are beyond those covered by Patient’s private insurance plan (“Plan”).

SERVICES AND BENEFITS In exchange for the subscription Membership Fees (defined below), Practice will make available to Patient the Services outlined in Schedule A. Practice reserves the right to update the schedule of Services from time to time, and if it does, it will notify Patient of any changes within sixty (60) days after a change is made and secure Patient’s voluntary consent to any such modification of Services.

PROGRAM FEES For the Services, the subscribing Patient will pay voluntary subscription fees (“Membership Fees”) for the Services offerings in Schedule A. The Membership Fees cover the program Services for a period of twelve (12) months from the date Patient signs this Agreement and may be payable on a monthly or annual basis. The Program Fees may increase from time to time with the voluntary consent in advance by Patient but will apply to renewal terms. In the event of Membership Fees increases, Patient will receive notification in writing and the option of consenting to such increase.

PAYMENT OPTIONS The Program Fees can be paid with bank account ACH or credit card. If Membership fees are not paid in full by the end of the month, the Agreement is canceled.

RENEWALS AND TERMINATION The Membership Fees cover all of the Services subscribed to by Patient for a period of one (1) billing period. Patient will be automatically renewed for membership into Practice each month unless Practice receives written notice from Patient of withdrawal from Practice thirty (30) days prior to Patient’s renewal date. Failure to pay the renewal Membership Fees before the expiration of the prior period may result in termination of enrollment in Practice. Patient is permitted to terminate this Agreement with a thirty (30) days’ written notice which includes Patient’s reason for termination. Practice is permitted to terminate this Agreement with a thirty (30) days’ prior written notice for unruly, threatening, or inappropriate behavior by providing Patient a written notice in accordance with the law.

HEALTH CARE SERVICES THAT ARE EXCLUDED FROM PRACTICE FEE The Membership Fees cover only the Services subscribed to by Patient. If Practice provides additional services, Patient and Practice may mutually agree upon any additional charges. Patient acknowledges that either Patient will be responsible for these additional charges. Any charges to Patient for any services outside of subscription fee will be at our usual, reasonable and customary rates and consented to in advance by Patient before any such charge is incurred.

EMAIL COMMUNICATION Patient acknowledges that communications with the Healthcare provider using e-mail, fax, instant messaging, and cell phone are not guaranteed to be secure or confidential methods of communications. The Provider’s obligation to guarantee confidentiality with respect to correspondence using such means of communication. Patient acknowledges that all such communications may become a part of the medical record. In providing an e-mail address, Patient authorizes Azumaya Health to communicate by e-mail regarding “protected health information” (PHI) (as that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and it’s implementing regulations). Patient acknowledges and understands that email is not a good medium for urgent or timesensitive communications. If communication is time sensitive, Patient must communicate with Practice by telephone or in person.

APPOINTMENTS AND SCHEDULING Appointments with Practice are scheduled through Practice office to ensure ample time is given to each Patient. If Patient has an urgent concern, Patient shall call Practice office and Patient will be given an appointment that will accommodate the urgency. The Practice patient schedule is organized in such a way that it provides and protects extensive time for each Patient. Walk-ins are not conducive to the thoughtfully planned schedule, so Practice advises Patient to call for any needs that require Patient to have time with Practice physician. VACATIONS AND ILLNESS FOR PRACTICE PHYSICIAN Patient acknowledges that there may be times that Patient cannot contact a Practice physician due to the physician’s vacations or illness, or due to technical defects with either Patient’s or Practice’s electronic communication equipment. Patient acknowledges that, should a Practice physician become unavailable, Practice shall make every effort to give advance notice to Patient so that Services can be scheduled on another date.

COMPLIANCE WITH LAW In establishing the Services, Practice intends to do so in compliance with all applicable laws. This Agreement shall be governed by and construed in accordance with the laws of the state of Florida, in which Practice is licensed and practicing, without application of choice-of-law principles. If there is a change of any law, regulation or rule, federal, state or local, which affects the Agreement or the activities of either Party under the Agreement, or any change in judicial or administrative interpretation of any such law, regulation or rule, this Agreement shall be deemed modified so as to remain in compliance with such laws.

REJOINING THE PRACTICE In the event of a cancellation of membership, Patient may rejoin the Practice by paying a $199 reenrollment fee for each member. Patient eligibility to rejoin Azumaya Health is based on membership availability at that time.

AGREEMENT ASSIGNMENT AND MODIFICATIONS This Agreement may not be assigned to any other person by Patient. This Agreement replaces and supersedes all prior agreements between Patient and Practice. This Agreement may not be modified absent a writing signed by Patient and an authorized representative of Practice.

PRACTICE IS NOT AN INSURER Practice is not an insurance company and is not promising unlimited care for the Membership Fees. The patient has the responsibility to check with their human resources department or their accountant regarding the use of these funds to pay for their membership with Health Savings, Health Reimbursement, and Flexible Spending Accounts for Direct Primary Care. “This agreement is not health insurance, and the primary care provider will not file any claims against the patient’s health insurance policy or plan for reimbursement of any primary care services covered by the agreement. This agreement does not qualify as minimum essential coverage to satisfy the individual shared responsibility provision of the Patient Protection and Affordable Care Act, 26 U.S.C. s. 5000A. This agreement is not workers’ compensation insurance and does not replace an employer’s obligations under chapter 440.”

PATIENT ACKNOWLEDGES THAT HE/SHE HAS CAREFULLY READ THIS AGREEMENT, WAS AFFORDED SUFFICIENT OPPORTUNITY TO CONSULT WITH LEGAL COUNSEL OF HIS/HER CHOICE AND TO ASK QUESTIONS AND RECEIVE SATISFACTORY ANSWERS REGARDING THIS AGREEMENT, UNDERSTAND HIS/HER RESPECTIVE RIGHTS AND OBLIGATIONS UNDER IT, AND SIGNED IT OF HIS/HER OWN FREE WILL AND VOLITION. By signing below, I am agreeing to enrollment in Practice and the terms of this Agreement as detailed above.

PATIENT Signature: ___________________________________ Date: ______________________

Name: _________________________________________________

PRACTICE Signature: _________________________________ Date: ________________________