Patient Agreement Form Today's Date* MM slash DD slash YYYY This Patient Agreement (“Agreement”) is entered into between The Angel Plan Medical, LLC, a Texas limited liability company, located at 269 East Ovilla road, Suite 4, Red Oak, Texas 75154 (“Angel Plan”), and Federico Maese, (“Physician”) in their capacity as agents of Angel Plan and you, (“Patient”). Background The Provider, who specializes in family medicine, delivers care on behalf of Angel Plan at the address set forth above. In exchange for certain fees paid by You, Angel Plan through its Provider, agrees to provide Patient with the Services described in this Agreement on the terms and conditions set forth in this Agreement. Patient. A patient is defined as those persons for whom the Provider shall provide Services, including the signatory to this Agreement. Services. As used in this Agreement, the term Services, shall mean a package of services, both medical and non-Medical, and certain amenities, which are offered by Angel Plan and set forth in Appendix 1, attached hereto and incorporated herein for all purposes (collectively “Services”). This Agreement shall commence on the date signed by the parties below and shall continue for a period of 6 month or one year, automatically renewed for 6 months or one year periods by Patient’s payment of the applicable fee. 6-month membership is $40/mo. commitment with guaranteed $40 fixed office visits. 1-year membership is $30/mo. with $30 fixed office visits. Fees. In exchange for the Services described herein, Patient agrees to pay Angel Plan according to the membership model in which the patient selects. The membership fees follow below: The Angel Plan 6 month membership $40/mo. or $240The Angel Plan 1 year membership $30/mo. or $360 As used in this Agreement, the term Medical Services shall mean those medical services that Physician, himself is permitted to perform under the laws of the State of Texas and that are consistent with his/her training and experience as a family medicine provider, as the case may be. Insurance or Other Medical Coverage. Patient acknowledges and understands that this Agreement is not an insurance plan, and not a substitute for health insurance or other health plan coverage (such as membership in a PPO). It will not cover hospital services, or any services not personally provided by Angel Plan, or its Physicians. Patient acknowledges that Angel Plan has advised that patient obtain or keep in full force such health insurance policy(ies) or plans that will cover Patient for general healthcare costs. Patient acknowledges that this Agreement is not a contract that provides health insurance, and this Agreement is not intended to replace any existing or future health insurance or health plan coverage that Patient may carry. Termination. 6 month plan: A patient may terminate the membership at any time after four months. (Patient must have paid at least four monthly payments) One year plan: A patient may terminate the membership at any time after ten months. (Patient must have paid at least ten monthly payments). Terminating either membership must be done in writing with a 30-day notice. Communications. You acknowledge that communications with Provider using e-mail, facsimile, video chat; instant messaging, and cell phone are not secure or confidential methods of communications. As such, Patient expressly waives Providers obligation to guarantee confidentiality with respect to correspondence using such means of communication. By providing Patient’s e-mail address to Angel Plan, (a) Patient authorizes the Angel Plan and its Physicians to communicate with Patient by e-mail regarding Patient’s “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), and (b) (i) E-mail is not a secure medium for sending or receiving PHI and, there is always a possibility that a third party may gain access; (ii) Although Provider will make all reasonable efforts to keep e-mail communications confidential and secure, neither Angel Plan, nor Physician can assure or guarantee the absolute confidentiality of e-mail communications; (iii) In the discretion of Provider, e-mail communications may be made a part of Patient’s permanent medical record; and, (iv) Patient understands and agrees that e-mail is not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation in which Patient could reasonably expect to develop into an emergency, Patient shall call 911 or the nearest Emergency room, and follow the directions of emergency personnel. If Patient does not receive a response to an e-mail message within one day, Patient agrees to use another means of communication to contact the Provider. Neither Angel Plan nor the Provider will be liable to Patient for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient. Change of Law. If there is a change of any law, regulation or rule, federal, state or local, which affects the terms and conditions of this Agreement or the activities of either party under the Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and either party reasonably believes in good faith that the change will have a substantial adverse effect on that party’s rights, obligations or operations associated with the Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms and conditions of this Agreement. If the parties are unable to reach an agreement concerning the modification of the Agreement within forty-five days after of date of the effective date of change, then either party may immediately terminate the Agreement by written notice to the other party. Severability. If for any reason any provision of this Agreement shall be deemed by a court of competent jurisdiction to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of the Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable. Reimbursement for services rendered. If this Agreement is held to be invalid for any reason and, as a result, if Angel Plan is required to refund all or any portion of the fees paid by Patient, Patient agrees to pay Angel Plan an amount equal to the reasonable value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid. No amendment of this Agreement shall be binding on a party unless it is made in writing and signed by all the parties. Notwithstanding the foregoing, the Physician may unilaterally amend this Agreement to the extent required by federal, state, or local law or regulation (“Applicable Law”) by sending Patient 30 days advance written notice of any such change. Any such changes are incorporated by reference into this Agreement without the need for signature by the parties and are effective as of the date established by Angel Plan except that Patient shall initial any such change at Angel Plan’s request. Moreover, if Applicable Law requires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been originally expressly set forth in this Agreement. Assignment. Neither this Agreement nor any rights Patient may have hereunder may be assigned or transferred by Patient. Relationship of Parties. Patient and the Provider intend and agree that the Provider, in performing his duties under this Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and/or the United States Department of Labor, and the Provider shall have exclusive control of his work and the manner in which it is performed. Legal Significance. Patient acknowledges that this Agreement is a legal document and creates certain rights and responsibilities. Patient also acknowledges having had a reasonable time to seek legal advice regarding the Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of the Agreement. Miscellaneous; This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted. Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text. Entire Agreement: This Agreement and its Appendix contain the entire agreement between the parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement. Jurisdiction: This Agreement shall be governed and construed under the laws of the State of Texas and venue for all disputes arising out of this Agreement shall be located in Red Oak, Ellis County, Texas. All written notices are deemed served if sent to the address of the party set forth herein by first class U.S. mail or overnight delivery. The parties have signed duplicate counterparts of this Agreement on the date first written above. FullName* Email* Phone*Patient Address* Street Address Address Line 2 City State / ProvinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP / Postal Code SignatureHiddenSkillsInterest CommentsThis field is for validation purposes and should be left unchanged.