Telehealth Women’s Health & Menopause Membership Agreement

Preferred Family Medicine

Mark Schumacher, M.D.

9120 Double Diamond Pkwy

Reno, NV 89521

(P) 775-204-0150 | (F) 775-501-6360

This Preferred Family Medicine (“PFM”) Telehealth Membership Agreement (the “Agreement”) outlines the terms under which you (the “Member”) will participate in the Telehealth Women’s Health & Menopause Program provided by Mark Schumacher, MD (“Physician”).

1. Term of Agreement

The term of this Agreement is three (3) months, beginning on the date of the initial membership payment.
This Agreement shall automatically renew every three (3) months unless canceled in accordance with Section 9.

2. Nature of Services

This Agreement is:

• Not health insurance


• 100% telehealth-based care


• Limited to the scope of women’s health, menopause, and hormone-related care

This Agreement does not include in-person visits or general primary care services.

3. Membership Fees

• Membership Fee: $450 per 3-month period


• Billing: Automatically charged every 3 months


• Payment Method: Credit card, debit card, or ACH on file

Member authorizes PFM (or its payment processor) to charge recurring fees without separate authorization.
Failure of payment may result in suspension or termination of services.

Preferred Family Medicine may, at its discretion, offer alternative membership rates to select patients.
Any such rate applies only during continuous, uninterrupted enrollment and will be void upon cancellation,
with any re-enrollment subject to the then-current standard rate. PFM reserves the right to modify or
discontinue such arrangements at any time.

4. Included Services

Membership includes:

• Telehealth visits (video or phone)


• Evaluation and management of:
  
  
  
  • Menopause and perimenopause
  
  
  • Hormone Replacement Therapy (HRT)
  
  
  • Female hormonal health conditions
  
  
  
  


• Prescription management (non-controlled substances)


• Clinical messaging related to care


• Lab review and interpretation (when ordered by Physician)

5. Non-Included Services

This membership does not include:

• In-person care or physical examinations


• Emergency or urgent care services


• Hospital care or specialist services outside scope


• Imaging, lab fees, or medications

6. Labs and Medications

Members may optionally utilize:

• Discounted lab pricing through PFM


• Discounted medications via PFM’s in-house pharmacy (when applicable)

These services are not included in the membership fee and are billed separately.

7. Communication and Availability

Members will have access to:

• Secure messaging platform


• Scheduled telehealth visits

PFM aims to respond within one business day, though this is not guaranteed.
This service is not intended for emergencies. Members should call 911 or go to the nearest emergency room when appropriate.

8. Medicare Opt-Out Acknowledgment

Physician has opted out of Medicare.
By signing this Agreement, Member acknowledges:

• PFM and Physician will not bill Medicare


• Member agrees not to seek reimbursement from Medicare


• This Agreement constitutes a private contract under Medicare regulations

9. Termination and Refund Policy

a. Member Cancellation

• Member may cancel at any time with written notice


• Membership remains active through the end of the current 3-month term


• Cancellation prevents future billing only

b. Refund Policy

• Membership fees are non-refundable once the billing period begins


• This includes:
  
  
  
  • Lack of utilization
  
  
  • Early discontinuation
  
  
  
  


• If no services have been rendered, PFM may consider a partial refund at its sole discretion

c. Practice-Initiated Termination

PFM may terminate this Agreement at any time. A prorated refund may be issued at PFM’s discretion,
unless services have already been provided that constitute substantial value.

10. Scope Limitations

Member understands:

• This program is not a replacement for primary care


• Member is encouraged to maintain a separate primary care provider


• Certain conditions may require referral to in-person care

11. Additional Charges

Member understands that services not covered by this Agreement—including labs, medications, or external services—must be paid at the time of service.

12. No Guarantee of Outcomes

PFM and Physician make no guarantees regarding:

• Clinical outcomes


• Symptom improvement


• Medication effectiveness

13. Telehealth Consent

Member acknowledges:

• Care is delivered via telehealth


• There are limitations compared to in-person care


• Physician may recommend in-person evaluation when appropriate

14. Practice Rights

PFM reserves the right to:

• Modify services or pricing with 30 days notice


• Refuse or terminate membership


• Limit services based on clinical appropriateness

15. Informed Consent for Telehealth Services

By entering into this Agreement, Member provides informed consent to receive medical care via telehealth technologies,
including video, phone, and electronic messaging.

Member acknowledges and understands the following:

a. Nature of Telehealth

Telehealth involves the use of electronic communications to enable healthcare providers to diagnose, consult,
treat, and educate patients remotely.

b. Limitations of Telehealth

Member understands that telehealth has inherent limitations, including but not limited to:

• The inability to perform a hands-on physical examination


• Potential for incomplete or limited clinical information


• Reduced ability to assess certain acute or complex conditions


• Possible need for in-person evaluation, laboratory testing, or imaging to confirm diagnosis or guide treatment

Member acknowledges that certain conditions may not be appropriate for telehealth care and may require referral to an in-person provider.

c. Technology Risks

Member understands that telehealth services rely on technology, which may involve:

• Interruptions, delays, or technical failures


• Poor video/audio quality


• Unauthorized access risks despite reasonable safeguards

PFM utilizes secure, HIPAA-compliant platforms when available but cannot guarantee absolute confidentiality of electronic communications.

d. Privacy and Security

Member understands that:

• Reasonable efforts are made to protect privacy and confidentiality


• Communications may occur over secure digital platforms


• Member is responsible for ensuring they are in a private location during telehealth visits

e. Emergency Situations

Member understands that telehealth services are not appropriate for emergency care.
In the event of a medical emergency, Member agrees to:

• Call 911, or


• Proceed to the nearest emergency room

f. Patient Responsibilities

Member agrees to:

• Provide accurate, complete, and up-to-date medical information


• Participate in telehealth visits in a safe and appropriate environment


• Follow Physician recommendations, including seeking in-person care when advised

g. Consent and Right to Withdraw

Member understands that:

• Participation in telehealth is voluntary


• Consent may be withdrawn at any time by providing written notice


• Withdrawal of consent may limit Physician’s ability to provide care under this Agreement

h. No Guarantee of Diagnosis or Outcome

Member acknowledges that:

• Telehealth may result in different clinical decisions than an in-person evaluation


• No guarantees are made regarding diagnosis or treatment outcomes

16. Entire Agreement

This Agreement constitutes the entire understanding between Member and PFM regarding this program.

17. Authorization and Acknowledgment

By signing below, or acknowledging digitally, Member acknowledges understanding and agreement with the terms of this Agreement and Telehealth Consent.