Lifeforce Medical Patient Agreement
Effective Date: February 8, 2022
Updated Date: February 8, 2022
This Patient Agreement (“Patient Agreement”) governs your use of the medical and coaching services (“Provider Services”) provided by Van Maele Medical, M.D., P.C., a California professional corporation d/b/a Lifeforce Medical CA, P.C., Lifeforce Medical NJ, P.C., Lifeforce Medical KS, P.A., and Lifeforce Medical, P.A. (collectively, “Lifeforce Medical”). Please read this Patient Agreement carefully before using Lifeforce Medical’s medical services (the “Medical Services”).
Lifeforce Digital, Inc. (“Lifeforce Digital”) provides technology and non-medical services to consumers including patients of Lifeforce Medical (“Membership Services”), and the TERMS OF USE govern your use of the Membership Services provided by Lifeforce Digital. Please read the Terms of Use carefully before using Lifeforce Digital’s Membership Services.
By clicking the “check box” on www.mylifeforce.com and other affiliated websites (collectively, the “Site”), and the mobile application (“App”) as the registered user, or by signing below as either the patient, or other person lacking the ability to consent (collectively “You”), You acknowledge to have read, accepted and become legally bound to the terms of this Agreement set forth below, including in the Telehealth Services Consent contained herein. The terms “You” or “you” shall also mean the patient or recipient of health care services.
Please refer to our Notice of Privacy Practices to learn how Lifeforce Medical collects, uses, shares and protects your Protected Health Information (as defined under the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (“HIPAA”)). Our use of the term “PHI” as defined under HIPAA does not mean that Lifeforce Medical is a “Covered Entity” as defined under HIPAA.
DO NOT USE THE PROVIDER SERVICES, INCLUDING THE TELEHEALTH SERVICES, FOR EMERGENCY OR LIFE-THREATENING MEDICAL MATTERS. FOR ALL LIFE-THREATENING MATTERS, IMMEDIATELY CALL 911 OR GO TO THE NEAREST EMERGENCY ROOM.
- Updates to the Patient Agreement
Lifeforce Medical may, in its sole discretion, without prior notice to You, revise this Patient Agreement at any time. Should this Patient Agreement change materially, Lifeforce Medical will update the “Effective” date noted above with an “Updated” date and post a notice regarding the updated Patient Agreement. If You do not agree with the proposed changes, You should discontinue your use of Lifeforce Medical’s before the effective date of the change. If You continue using the Lifeforce Medical services after the Updated date, you will be bound by the updated Patient Agreement.
- Your Financial Responsibility
You agree to pay Lifeforce Medical all applicable charges and payment responsibility at the prices then in effect for the Provider Services provided to You. You will be charged for the Medical Services provided to You by Lifeforce Medical. You authorize Lifeforce Medical and its agents to charge Your chosen payment method (Your “Payment Method”) for the Medical Services provided to You. If Your Payment Method is invalid at the time payment is due, You agree to pay all amounts due upon demand. The third-party services provider who manages Your Payment Method may impose terms and conditions on You, which are independent of this Patient Agreement, and You agree to comply with those terms. Lifeforce Medical reserves the right to correct any billing errors or mistakes even if payment has already been requested or received. Payment in full is due when the Medical Services are first delivered. No refunds will be issued if the Medical Services are terminated.
- Permission to Treat
By accepting this Patient Agreement, You give Lifeforce Medical permission to care for You. You may withdraw this consent at any time by no longer seeking Medical Services from Lifeforce Medical.
You understand and agree that as part of providing Medical Services to You, your PHI may be released to an online personal health record and via communication with Lifeforce Medical clinicians electronically (in accordance with our Notice of Privacy Practices).
- Medical Services Termination
You may terminate your use of the Medical Services at any time by not using the Medical Services anymore. We may terminate Your use of the Medical Services at any time in our reasonable discretion, for causes including but not limited to illegal conduct such as falsifying information to obtain controlled substances, abusive and threatening behavior, and continued refusal to pay for our Medical Services. We may terminate Your use of the Medical Services by sending notice to You at the mail or email address you provided to us or by otherwise contacting You. No refunds will be issued if the Medical Services are terminated.
- Consent to Electronic Communications
You agree that Lifeforce Medical may send the following to you by email or by posting them on our Site: legal disclosures; these Provider Services Terms, including the Telehealth Services Consent and Notice of Privacy Practices; future changes to any of the above; and other notices, policies, communications or disclosures and information related to the Medical Services.
- Disclaimers
TO THE MAXIMUM EXTENT NOT PROHIBITED BY LAW, EXCEPT IN CASE OF NEGLIGENCE OR WILLFUL MISCONDUCT, WE, LIFEFORCE MEDICAL, LIFEFORCE DIGITAL, AND OUR AFFILIATES, PARTNER PROVIDERS, EMPLOYEES, OFFICERS, DIRECTORS OR AGENTS WILL NOT BE RESPONSIBLE FOR ANY LOSS OR DAMAGE, INCLUDING PERSONAL INJURY OR DEATH, RESULTING FROM ANYONE’S USE OF OR INABILITY TO USE THE PROVIDER SERVICES.
- Limitation of Liability
TO THE MAXIMUM EXTENT NOT PROHIBITED BY LAW, IN NO EVENT WILL WE, LIFEFORCE MEDICAL, LIFEFORCE DIGITAL, AND OUR AFFILIATES, PARTNER PROVIDERS, EMPLOYEES, OFFICERS, DIRECTORS OR AGENTS BE LIABLE FOR ANY CONSEQUENTIAL, EXEMPLARY, INCIDENTAL, SPECIAL OR PUNITIVE DAMAGES, INCLUDING WITHOUT LIMITATION THOSE RELATING TO LOST PROFITS OR THE COST OF SUBSTITUTE PRODUCTS OR SERVICES ARISING OUT OF OR IN CONNECTION WITH THE MEDICAL SERVICES OR FROM THE USE OF OR INABILITY TO USE THE MEDICAL SERVICES.
- Telehealth Services Consent
Lifeforce Medical may directly provide Medical Services to You using virtual technology when the Lifeforce Medical provider and patient are not in the same physical location, and/or deliver health care services virtually, including by a medical provider or via digital or automated tools, including without limitation tools for medical or health-related diagnosis or treatment and coaching (the “Telehealth Services”).
- Use of the Telehealth Services, Telehealth Services Consent
You agree to the following terms with respect to use of the Telehealth Services:
- You understand that there may be possible risks and limitations of the Telehealth Services, including that it may be possible that your condition cannot be treated via the Telehealth Services.
- You agree NOT to use the Site or App using an unsecured public Wi-Fi or other unsecure electronic communication.
- You agree NOT to record any audio or visual communication transmitted via the Site or App, including Telehealth Services, without the express consent of all communicating parties.
- General Provisions
This Patient Agreement, including the Telehealth Services Consent, makes up the entire agreement relating to your use of the Medical Services.
BY CLICKING THE “CHECK BOX” BELOW, I HEREBY ACCEPT THE TERMS OF THIS PATIENT AGREEMENT.