PRIVATE PAY CONTRACT

This Private Pay Contract (“Agreement”) is made between Middlebelt Medical Center, P.L.C.,d/b/a as Virtual Weight Management , and its subsidiaries/affiliated/contracted entities, with a conducting business address of 16332 Middlebelt RD Livonia,MI 48154(“Company”), and you in your capacity as a patient/parent/legal guardian (“Patient”). This Agreement is made by Company for itself and on behalf of its related entities and/or contracted physicians, other health care professionals,employees, and contractors (the “Professionals”). Company is not necessarily the provider of medical services; medical treatment may be provided to Patients utilizing a separate entity or by Professionals who are medical
professionals.

The Patient may receive a copy of this Agreement at Patient’s email address by requesting a copy via e-mail at staff@virtualweightmanagement.com ; Company will provide a copy of this Agreement to you within five (5) days of receiving your request

The Patient desires unique services and benefits to be provided by Company/the Professionals that are likely not covered or otherwise likely not reimbursable under a private health insurance policy, private health plan, or federal or state government program (including, but not limited to, Medicare/Med-icaid/Tri-Care), in which Patient might be enrolled (each an “Insurer”). Company/the Professionals desireto provide unique services and benefits to Patient for which Company/the Professionals likely cannot, and in any event will not, seek reimbursement for with an Insurer in which Patient might be enrolled.

By electronically signing this Agreement, Patient and Company/the Professionals hereby agree, for valuable consideration, to enter into a relationship for the provision of specified services under the following terms and conditions.

Patient Responsibilities

In addition to any other responsibilities and/or obligations Patient has under this Agreement, Patient is responsible for providing Company with accurate and complete medical records, patient history, and descriptions of Patient’s condition and physical well-being. Patient is responsible for requesting and bearing the costs of any medical records necessary for Company/the Professionals to provide the Company’s services. Patient understands that, as with any service, to the extent that information provided is not accurate and complete, the Company’s services will be materially affected.

Jurisdiction and Practice of Medicine
Patient acknowledges, understands, and agrees that by Patient’s seeking to use Company’s services,

Patient is:

• Virtually travelling to the State where the Professional is located, and for convenience and other purposes availing themselves of Company’s Services in said State in the same manner as if Patient had physically driven to such State;
• Irrevocably agreeing that the Services and this Agreement are provided, and entered into, in the State where the Professional is located, and not in the state where Patient is physically located.
  Further, Patient agrees that they will not bring any action in the state where Patient is physically located, it being acknowledged that sole jurisdiction and venue are in the State where the Company is located, and that Patient has no rights vis-à-vis the Company or the Professionals in the Patient’s state (if such State is other than where Company is located);
• To the extent that the state where Patient is physically located attempts to assert jurisdiction over the Company or the Professionals, whether through its state professional licensing board(s) or otherwise, Patient agrees to cooperate with Company/the Professionals, and otherwise use Patient’s best efforts, with respect to asserting the matters agreed to in this Section.

Our Services

Company and/or the Professionals agree to perform online weight loss services via telehealth including, but not limited to, the diagnosis and/or development of a weight loss treatment plan, all utilizing Company’s proprietary system, methods, and protocols (the “Services”). The Services may be amended or modified to the extent necessary to reflect any change in interpretation or terms of coverage and
benefits of any private health insurance policy, private health plan or government program, including, but not limited to, Medicare, in which Patient is enrolled.

Fees

a) Monthly Automatically Renewing Fees based on the program you choose, billed on a monthly recurring, automatically renewing, basis, based on the date that Patient first signs up for the Services. The monthly Fees automatically renew Five (5) Days prior to the end of each month.

Patient may cancel at any time. If Patient cancels during a monthly Service period, the Patient will NOT receive a pro-rata refund of the remainder of the month’s Services, but will instead be allowed to access the Services for the remainder of the month. If Patient cancels the Services in the Five (5) Days prior to the next recurring, automatically renewing, monthly billing cycle, they will be charged for the next month of Service (during which such time they will have access to the Service), and their Service will end at the expiration of such next month. For example, if Patient signs up for the Service on August 20th, they will need to cancel Service prior to September 15th in order to avoid incurring the charge for the September 20th through October 20th billing cycle.

b) Re-Activation Fee. If Patient cancels the Service, and later re-activates the service, Company will not charge patient any re-activation fee.

THE FEES ABOVE DO NOT INCLUDE THE COSTS OF ANY PRESCRIPTION MEDICINES OR OTHER TREATMENTS OR PRODUCTS THAT MAY BE RECOMMENDED/PRESCRIBED BY COMPANY OR
THE PROFESSIONALS. I UNDERSTAND THAT I AM WHOLLY RESPONSIBLE FOR THE PAYMENT
OF ANY SUCH DRUGS OR MEDICINES OR TREATMENTS. TO THE EXTENT THAT SUCH DRUGS/
SUBSTANCES ARE DISCUSSED BY COMPANY OR THE TREATING PARTIES, NEITHER COMPANY
NOR THE TREATING PARTIES ARE MAKING CLAIMS, IMPLIED OR STATED, AS TO THEIR EFFI-
CACY FOR WEIGHT MANAGEMENT, WEIGHT LOSS, OR ANY OTHER MEDICAL CONDITION.

c) Fees for Products and Prescription Medications Sold (IF ANY). In the event that Company/the Professionals recommends and/or prescribes a product or medication and Patient requests Company/the Professionals dispense said products or prescription medications (if Company/the Professionals elect to do so), Patient agrees that Patient will be charged for such medications at Company’s then-current charge for the same.

The Fees set forth above may be changed by Company upon reasonable prior notice; in such event Patient may cancel as set forth below prior to incurring the changed Fees. Company may, but is not required to, offer discounted Fees or types of incentives to Patient from time-to-time. Company may also offer discounted Fees or other types of incentives to other customers of Company, without changing Patient’s liability for the Fees incurred hereunder, it being explicitly agreed that Company is under no obligation to extend such other discounted fees or incentives to Patient.

Patient agrees and acknowledges the following regarding the Fees:

• No refunds will be issued for any Fees, no warranties of any type
  are associated with the Services, and by their nature the Ser-
  vices are not returnable;
• No other cancellation, refund, or return policy applies to the Services. The Patient may cancel at any time by e-mailing staff@virtualweightmanagement.com, or calling 734-522-8590 Regardless of cancellation, no refunds will be issued; and
• Patient acknowledges that Patient is capable of printing and/or
  otherwise retaining a copy of this notice and Agreement, includ-
  ing the provisions set forth above regarding how the Patient may
  cancel this Agreement.

Agreements Regarding the Services

By electronically signing this Agreement, Patient agrees, and understands that the Services are unique and provided with certain benefits and limitations, including as follows:

1. Patient agrees to be fully responsible for payment of the Services, and understands that no Insurer reimbursement will be provided.

2. For Services provided herein, Patient cannot, and will not, bill to or seek reimbursement from any Insurer in which Patient is enrolled. Patient agrees not to submit a claim (or request that Company or the Professionals submit a claim) for the services provided pursuant to this Agreement, to any Insurer.

3. Services are not covered and otherwise not reimbursable by any Insurer. Accordingly, Patient understands and acknowledges that the Services convey value and benefits that Patient does not already receive from any Insurer in which Patient is enrolled. To the extent any one or more element of the Services are considered covered and reimbursable benefits, the Fee is consideration for the remaining items/portions of the Services.

4. Patient understands that no Insurer reimbursement limits (including Medicare’s limiting charge) apply to the services in question.

5. Patient understands that Medi-Gap plans do not, and other supplemental insurance plans may not, make payment for the services because payment is not made under the Medicare program.

6. Patient acknowledges that they have the right to have these items and services provided by other physicians for whom Insurers may make payments.

7. Patient understands that Insurer payment will not be made for any items or services furnished by the physician that otherwise would have been covered by an Insurer if there was no private contract and a proper Insurer covered claim was made.

8. Patient understands that he/she enters into this contract with the knowledge that he or she has the right to obtain Insurer covered services and items from other physicians, and that the beneficiary is not compelled to enter into private contracts that apply to other Insurer services furnished by other physicians.

9. Patient is not currently facing an emergency or urgent health care situation.

10. Physicians associated with Company and/or the Professionals have not been excluded from the Medicare program.

11. Company may cancel the Services at any time by providing Patient notice of Company’s cancellation.

Patient represents that he/she has read and fully understood and freely covenant to accept and agree to the rights and obligations under this Agreement. Further, Patient represents that they have read and fully understood and agreed to the Company’s: (i) Consent for Online Weight Loss Diagnosis and Treatment and Acknowledgment of Limited Physician-Patient Relationship; (ii) the Company Notice of Medical Information Privacy Practices; (iii) the Company Website Privacy Policy; and (iv) the Company’s Website Terms of Use.

Notice of Medical Information Privacy Practices

By electronically signing below, Patient acknowledges Patient’s receipt of Company’s Notice of Medical Information Privacy Practices, located here, which provides information about how Company may use and disclose Patient’s protected health information. We encourage Patient to read it in full. The Notice of Medical Information Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by accessing our website virtualweightmanagement.com or by contacting our organization at: 734-522-8590. If you have any questions about our Notice of Medical Information Privacy Practices, please contact us at 734-522-8590

Electronic Signature

By electronically signing below, I am agreeing to conduct transactions electronically, and intend for my electronic signature to be a binding electronic signature/contractual obligation. Further, Patient understands and acknowledges that they are digitally receiving a copy of this Agreement concurrently with executing the Agreement, in that Patient has the ability to print and/or retain a copy of this Agreement.