SECTION 3: SIGNATURE PATIENT'S AGREEMENT AND RELEASE SECTION 3. SIGNATURE PATIENT'S AGREEMENT AND RELEASE THIS AGREEMENT is made and executed on ___________________, between Ultimate Prime LLC. (hereinafter referred to as "Ultimate Prime") and
_______________________________________________________________________ ______________________ (hereinafter referred to as "Patient"). IN CONSIDERATION of the Ultimate Prime, LLC., providing Patient with medical management, administrative and referral services, Patient acknowledges, understands and agrees to the following terms and conditions as set forth herein. MEDICAL HISTORY FORM: Patient will submit an accurately completed Medical History Form. Patient agrees to truthfully, accurately and completely respond in completing this form and acknowledges, understands and agrees that failure to provide truthful, accurate and complete information on this form to Ultimate Prime or to the "PHYSICIAN(S)" referred to by Ultimate Prime will result in inappropriate treatment. AUTHORIZATIONS: Patient authorizes Ultimate Prime to obtain on Patient's behalf medical laboratories, diagnostic testing, Physician(s) and dispensing pharmacies. In addition, Patient authorizes and instructs Ultimate Prime and the Physician(s) referred by Ultimate Prime and dispensing pharmacies obtained on my behalf to provide medical care and prescribed pharmaceuticals based on the Medical History Form, laboratory diagnostic tests, and other information submitted to Ultimate Prime under this Agreement. Patient agrees to submit a photo identification for any blood testing pursuant to a Ultimate Prime or Physician(s) test requisition. Patient acknowledges, understands and agrees that laboratory, diagnostic testing services supplied or obtained by Ultimate Prime, and medical services provided to the Patient by Physician(s), are not covered or reimbursed by Medicare or other insurance. PHYSICIAN(s): Patient acknowledges, understands and agrees that Ultimate Prime is a medical management, administration and referral service and does not direct, control or influence the medical treatment decisions made by Physician(s). Patient acknowledges, understands and agrees that Ultimate Prime Advisors are not licensed Physician(s). Patient acknowledges, understands and agrees that Ultimate Prime Physician(s) may not be licensed to practice medicine in Patient's state or country of residence. MEDICAL CARE SERVICES: Patient further acknowledges, understands and agrees that Ultimate Prime and Physician(s) are rendering the medical care, services and treatment and that Ultimate Prime is instructed and authorized to arrange for the prescribed pharmaceuticals to be dispensed and sent to the Patient by any pharmacy in the State or County of the Patient's residence. Your prescriptions can be filled at the pharmacy of your choice. INSTRUCTIONS AND TREATMENT: Patient acknowledges, understands and agrees to comply with the method of instructions, treatment and dosage schedules prescribed by Physician(s), to immediately cease any medical treatment prescribed by Physician(s) in the event of any adverse reaction or side effect arising from prescribed treatment, and to immediately provide Ultimate Prime and Physician(s) with written notice via email to info@ultimatehrt.com of any such adverse reaction or side effect. Patient acknowledges, understands and agrees that diagnosis and treatment may involve certain risks, including injury. IF THIS IS A MEDICAL EMERGENCY – CALL 911 IMMEDIATELY! HORMONE REPLACEMENT THERAPY: Patient acknowledges, understands, and agrees that the hormone blood level objective sought as a result of Patient's hormone replacement therapy, as prescribed by Physician(s), may be at the highest level of a standard reference range for Patient's age and sex, or, in some cases, above such range, to the level of a younger person, and that such range is experimental and may not render any benefits, but may result in unknown, adverse results. Patient is aware of the nature, risk of alternative methods of treatment and the possible consequences and/or complications involved in such hormone replacement treatment. Patient acknowledges, understands and agrees that recombinant human growth hormone replacement therapy involves the use of a medical drug approved for one purpose and are being used for new and different purpose in an effort to obtain a desired objective of medical treatment. Nonetheless, Patient consents to such care and treatment, and executes this Agreement with a complete, informed understanding of such hormone replacement therapy for the purpose of authorizing Physician(s) to administer such treatment to relieve body ailments and attempt to enhance Patient's physical condition and health. Patient further acknowledges, understands and agrees that the methods of medical treatment offered by Ultimate Prime and Physician(s) are not accompanied by any claims, guarantees, promises or warranties. PRIMARY-CARE PHYSICIAN: Patient represents that he or she is under the care of a primary-care Physician and that Patient will not rely or substitute the advice of the Ultimate Prime Physician(s) should it conflict with the advice given to Patient by Patient's primary-care physician. Before taking any medication prescribed by Physician(s), Patient agrees to have a comprehensive physical examination by his or her primary-care physician. Patient agrees to notify his or her primary-care physician and advise such physician that Patient is undergoing hormone replacement therapy. MEDICAL MALPRACTICE INSURANCE: Patient acknowledges, understands and agrees that under Florida law, Physician(s) are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. PHYSICIAN(S) HAVE DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This is permitted under Florida law subject to certain conditions. Florida law imposes penalties against non insured Physician(s) who fail to satisfy adverse judgments arising from claims of medical malpractice. This notice is provided pursuant to Florida Law. PROPRIETARY BUSINESS INFORMATION: During Patient's relationship with Ultimate Prime and Physician(s), Ultimate Prime and Physician(s) will convey to Patient a range of proprietary business information, including, confidential disclosures and trade secrets' business practices and Ultimate Prime’s customers and suppliers ("Confidential Information"). No matter how received by Patient during the parties' relationship. Patient acknowledges, understands and agrees that this Ultimate Prime Information is confidential, proprietary and uniquely valuable to Ultimate Prime and gravely affects the conduct of business of Ultimate Prime and Ultimate Prime’s goodwill. Patient acknowledges, understands and agrees not to disclose, divulge or communicate, in any fashion, form, or manner, either directly or indirectly, any of Confidential Information or take any action that may result in disclosure of Confidential Information to any third-party person, firm, or business. Patient acknowledges, understands and agrees that if the terms of this paragraph are breached, Ultimate Prime shall be conclusively deemed to be irreparably injured and shall be entitled to an injunction restraining Patient from disclosing any of the Confidential Information and to liquidated damages in the amount of Ten Million Dollars ($10,000,000.00). Patient acknowledges, understands and agrees that the amount of Ultimate Prime’s actual damages in such circumstances would be difficult, if not impossible, to determine with accuracy, but would be substantial in any event, and Patient agrees that such liquidated damages are not a penalty. JURISDICTION: This Agreement shall be governed, construed and enforced in accordance with the laws of the State of Florida, applicable to agreements made and to be performed entirely within the State of Florida, without regard to principles of conflict of laws. Any disputes arising out of, in connection with or with respect to this Agreement, shall be adjudicated in a court of competent jurisdiction sitting in the Palm Beach County, Florida and nowhere else. Patient hereby irrevocably submits to the jurisdiction of such court for the purposes of any suit, civil action or other proceeding arising out of, in connection with or with respect to this Agreement. In the event of any litigation arising out of this Agreement, the prevailing party shall be entitled to recover all expenses and costs incurred, including reasonable attorneys' fees and legal assistants' fees. WAIVER: Patient acknowledges, understands and agrees that Ultimate Prime is not responsible for the negligent or intentional acts or omissions of any healthcare provider or supplier to whom the Patient is referred. The total liability of Ultimate Prime, its officers, directors, employees, agents and stockholders for negligence or intentional acts is limited to the purchase price of any products through Ultimate Prime, Physician(s) or pharmacies, and that Ultimate Prime and Physician(s) will not be liable for any direct, indirect, special, incidental, consequential, or punitive damages. Patient acknowledges, understands and agrees this is a waiver of any and all liability(ies). INDEMNIFICATION: Patient covenants and agrees to indemnify, defend, protect and hold harmless Ultimate Prime and Physician(s) and their respective officers, directors, employees, stockholders, assigns, successors and affiliates ("Indemnified Parties") from, against and in respect of all liabilities, losses, claims, damages, punitive damages, causes of action, lawsuits, administrative proceedings, investigations, demands, judgments, settlement payments, deficiencies, penalties, fines, interest and costs and expenses suffered, sustained, incurred or paid by the Indemnified Parties in connection with, resulting from or arising out of, directly or indirectly, Ultimate Prime and/or Physician(s) rendering medical care, services, advice, and/or treatment, Patient's failure to disclose all relevant information regarding Patient's medical and physical condition, acts or omissions of Ultimate Prime or Physician(s), harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by Ultimate Prime or Physician(s). Patient is aware of the potential side effects associated with the above-described treatment, accepts all risks involved in taking medication and will not seek indemnification or damages from the Indemnified Parties. This Agreement contains the entire understanding of the parties and supersedes and merges all prior and contemporaneous agreements and discussions between the parties. Any and all representations or agreements by any agent or representative of either party not contained in this Agreement shall be null, void and of no effect. If any provision of this Agreement or the application thereof to any person or circumstances is held invalid or unenforceable in any jurisdiction, the remainder hereof, and the application of such provision to such person or circumstances in any other jurisdiction, shall not be affected thereby, and to this end the provisions of this Agreement shall be severable. Patient has read, understands and agrees to the terms and conditions disclosed herein, including, but not limited to the waiver and indemnity Ultimate Prime and Physician(s)
Medical Treatment Agreement This agreement between _____________________________________________ (Patient) and Ultimate Prime, LLC. LLC (Ultimate Prime) establishes guidelines and conditions required for the use of hormone replacement therapy (HRT) involving DEA "controlled" or "scheduled" medications. Ultimate Prime and Patient agree that these guidelines and conditions are an essential factor in maintaining a successful patient/physician relationship. Adverse side effects and/or physical/psychological dependence may develop after repeated use of these medications and therefore, these agents are prescribed with caution. THE PATIENT ACCEPTS AND AGREES TO THE FOLLOWING CONDITIONS: 01. I understand that the medical treatment offered by Ultimate Prime and their Physician(s) is not accompanied by any claims, guarantees, promises or warranties. 02. I understand that the medications I have purchased are prescribed for me based on diagnoses derived from my submitted medical history, blood work, and physical examination. They are to be used exclusively for treatment of these diagnoses. 03. I will not attempt to obtain "scheduled" hormone replacement therapy medications illegally or from any other healthcare practitioner without disclosing my current medication usage. I understand that it’s against the law to do so. 04. I will immediately report any adverse side effects related to the use of my medication to Ultimate Prime and discontinue use until advised to resume usage by Ultimate Prime. 05. I understand that the Ultimate Prime Physician (MD) and/or Licensed Physician's Assistant (PA-C) are available for questions and/or concerns during normal business hours throughout the course of my treatment. 06. I will safeguard my medications from loss or theft and will be responsible for their safekeeping. 07. I agree that these medications are for my personal use only and no other purpose and I will not share, sell, or trade my Medications. 08. I agree that I will use my medications at the prescribed rate and dosage and will keep the medication in its respective labeled container. 09. I agree and understand that federal regulations prohibit the return of prescribed medications. 10. I agree to contact Ultimate Prime 4-6 weeks into the start of my therapy (and every 3 months thereafter) to arrange for any follow-up blood testing and/or an office visit/consultation as required by the Ultimate Prime physician. 11. I agree and understand that completing the required forms, lab work and exams doesn't automatically qualify me for treatment. Only the prescribing physician can determine if I qualify. 12. I agree that the Ultimate Prime patient/physician relationship is not intended to replace the existing relationship with my current primary care provider (PCP) and my Ultimate Prime treatment will be in conjunction with the care provided by my current PCP. By checking this box, I acknowledge and understand that charges will appear on my Credit Card Statement as “Ultimate Prime LLC”. Patient’s Signature Date Most patients are very anxious to hear the results of their lab tests or other determinations made by our medical staff regarding their treatment. Due to a physician’s schedule, communication of the results, especially if they are within normal ranges, is sometimes delayed. Although all Ultimate Prime personnel, both professionals and non professionals, are part of the Health Care Operations of the practice, and therefore do not require a specific HIPAA consent form, Ultimate Prime takes the confidentiality of your personal health information very seriously and does not permit its personnel who are not directly involved in your medical assessments and treatment with access to your medical records without your written consent. By signing this form, you will give permission to allow your personal Ultimate Prime Client Liaison, or other administrative staff member, to communicate to you via phone, email, text message, in writing, or in person, protected health information pertaining to your medical care.This consent form does not allow Ultimate Prime to share your health information with any third-party for any reason. It simply authorizes our administrative staff to convey information from our medical staff to you, at your request. Understand that administrative staff cannot answer specific questions about the meaning of test results or treatment modalities, and if you have such questions after receiving the results, your client liaison, or other administrative staff member, will have a physician or other qualified health professional contact you to answer your questions. Authorization for Ultimate Prime to Release Health Information to Myself I,
______________________________________, hereby give my consent for Ultimate Prime LLC. (Ultimate Prime), and their non-medical professional and administrative staff to disclose my protected health information, Ultimate Prime Client Liaison, or other administrative staff, may communicate to me by phone, email, text message, in writing, or in person, information that assists the practice in carrying out operations related to my treatment; such as, appointment reminders, billing issues, and communications related to my clinical care, including laboratory test results. I acknowledge that such liaison or staff cannot answer specific questions about the results or course of my treatment as they are not a health professional, and any opinions and/or casual conversation they might gratuitously offer are not to be construed as medical advice, and that I can request a physician or other health professional to contact me to answer my questions.I understand that I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. I understand that this form is not required under the HIPAA privacy rule, but if I choose not to consent, or later revoke consent, Ultimate Prime may be unable to continue to provide treatment to me, but they will not do so without affording me a reasonable time, not longer than thirty days, to obtain a successor physician/practice.
Patient’s Signature
