Lifeforce Medical Patient Agreement

Effective Date: February 8, 2022

Updated Date: October 26, 2023

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”), 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 term “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.

1. 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 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.

2. 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.

3. 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 and other clinicians or providers electronically (in accordance with our Notice of Privacy Practices).

4. 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 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.

5. 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.

By clicking the “check box” on the “Site” as the registered user, you agree that Lifeforce Medical may contact you via messaging (secure), email, phone, text, or mail regarding the Medical Services, including electronic communications from Lifeforce Medical pertaining to your care and your health, which may include PHI. You understand that communication via email, text messages, and other electronic means selected by Lifeforce Medical may not be secure and could be viewed by unintended persons, and you agree to exchange of communications, to and from Lifeforce Medical via these electronic means. You agree to update your contact information to ensure accuracy.

If you later decide that you do not want to receive certain future communications electronically, please send an email to support@lifeforce.com, or a letter, with a copy also sent via email, to Lifeforce Medical, 1920 Olympic Blvd., Santa Monica, CA 90404. You may also opt out of certain electronic communications through your account or by following the unsubscribe instructions in any communication you receive from Lifeforce Medical. Your withdrawal of consent will be effective within a reasonable time after we receive your withdrawal notice described above.

Lifeforce Medical will need to send you certain communications electronically regarding the Medical Services. You will not be able to opt out of those communications – e.g., communications regarding updates to this Patient Agreement or information about billing. Your withdrawal of consent will not affect the legal validity or enforceability of the Patient Agreement provided to, and accepted by, you.

6. 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.

Any general advice that may be posted on the Site is for informational purposes only and is not intended to replace or substitute for any medical or other advice. To the maximum extent not prohibited by law, We make no representations or warranties and expressly disclaim any and all liability concerning any treatment, action by, or effect on any person following the general information offered or provided within or through the Medical Services. If you have specific concerns or a situation arises in which you require medical advice, you should consult with an appropriately trained and qualified medical services provider.

The Medical Services are intended for use only within the United States and its territories. We make no representation that the Medical Services are appropriate, or are available for use outside the U.S. Those who choose to access and use our Medical Services from outside the U.S. do so on their own initiative, at their own risk, and are responsible for compliance with applicable laws.

7. 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, WHETHER BASED ON CONTRACT, WARRANTY, PRODUCT LIABILITY, TORT OR OTHER LEGAL THEORY AND EVEN IF WE HAVE BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGES. SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE EXCLUSION MAY NOT APPLY TO YOU.

8. 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”). Telehealth may be used for diagnosis, treatment, care, follow-up and/or patient education, and may include, without limitation, the following: electronic transmission of patient medical records, medical images, and/or other patient data or information; synchronous (i.e., “real time”) and asynchronous (i.e., non-“real time”) interactions via audio, video, text, interactive questionnaire, and/or data or other electronic communications; automated, electronic or digital tools or services for diagnosis, care, treatment and/or communication pertaining to healthcare or medical matters; and output, transmission or exchange of data from medical devices, sound and video files. You understand that virtual encounters required to receive Telehealth Services via phone, email, video, or otherwise, could involve certain limitations and risk, such as unauthorized disclosure of PHI, and you hereby consent to the use of automated tools for diagnosis, care, treatment or communication pertaining to healthcare matters. You also acknowledge that such virtual encounters may involve care by a variety of types of Lifeforce Medical clinicians, including physicians, coaches, registered nurses, nurse practitioners, physician assistants, and other support or medical personnel in accordance with applicable laws and regulations.

Unless you object, you give permission to Lifeforce Medical to record and process your personal details and medical data generated during the provision of Telehealth Services. You may withdraw these permissions at any time by no longer seeking Telehealth Services from Lifeforce Medical.

9. 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, or that information transmitted through the Site may not be sufficient or of too poor of image quality, or there may be insufficient information or data to allow for appropriate medical decision making. Accordingly, you may be required to seek additional in-person medical care, alternative healthcare or emergency services. If your health or medical problem or condition persists after use of the Telehealth Services, you will immediately contact your primary medical services provider and seek appropriate additional in-person medical care or emergency care, as appropriate.

  • You understand that in rare circumstances, security protocols could fail, causing a breach of privacy that allows unauthorized persons access to your PHI.

  • You agree NOT to use the Site 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, including Telehealth Services, without the express consent of all communicating parties.

  • You understand that you are responsible for providing accurate information through the Site, including demographics and location information, medical histories, medication use, current adverse conditions, financial information, and keeping all such information current.

  • You agree to follow all recommendations, protocols and other instructions provided by Lifeforce Medical or Lifeforce Digital concerning the use of the Site and by Lifeforce Medical concerning the Telehealth Services.

10. General Provisions

  • This Patient Agreement, including the Telehealth Services Consent, makes up the entire agreement relating to your use of the Medical Services, and supersedes all prior agreements relating to the subject matter hereof.

  • We may change, suspend, or discontinue any of the Medical Services at any time. We will try to give you prior notice of any material changes to the Medical Services. We will not be liable to you or to any third party for any modification, suspension or discontinuance of the Medical Services.

  • This Patient Agreement does not confer any third-party beneficiary rights upon anyone other than you. You may not transfer any of your rights or obligations under this Patient Agreement to anyone else without our consent. Lifeforce Medical may assign our rights in connection with a merger, acquisition, or sale of assets, or by operation of law or otherwise without your consent.

  • Once an episode of care has begun or Medical Services have been paid for in full, there is no entitlement to a refund.

  • Even after termination, this Patient Agreement will remain in effect such that all terms that by their nature may survive termination will survive such termination.

If you have any questions about this Patient Agreement, please contact
support@mylifeforce.com