Medical Weight Management Agreement

Endocrinology · Obesity Medicine · Metabolic Health
www.ncendocrinology.com

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Medical Weight Management Agreement

This Medical Weight Management Membership Agreement ("Agreement") is between North County Endocrinology Associates, a California Professional Corporation ("Practice"), and the patient named above ("Member"). It establishes the terms under which the Practice provides physician-led medical weight management services on a membership basis, delivered primarily via telehealth across California.

This membership covers physician medical management and care coordination. It is NOT insurance, does NOT cover the cost of clinical visits, and does NOT cover the cost of medications.

The membership includes the following physician-led medical management services, provided primarily through asynchronous (secure messaging) telehealth:

• Asynchronous medical management of FDA-approved weight management medications between visits
• GLP-1 medication dose titration and optimization
• Side effect assessment and management
• Prior authorization submission and appeals for medications
• Progress monitoring and weight tracking
• Direct secure messaging with the physician via a HIPAA-compliant platform
• Guidance on manufacturer cash-pay programs and savings options if insurance denies coverage
• Metabolic health monitoring relevant to weight management

The membership does NOT include the cost of the initial or follow-up clinical visits, the cost of medications, laboratory testing, or imaging. These are billed separately as described in Section 4.

Care is delivered primarily asynchronously. After an initial video visit to establish the patient-physician relationship and treatment plan, ongoing management occurs through secure messaging. Additional video visits are scheduled only when clinically indicated, as determined by the physician.

The Practice prescribes only FDA-approved weight management medications. The Practice does NOT prescribe compounded semaglutide, compounded tirzepatide, or any non-FDA-approved formulations. Medications may include Wegovy, Zepbound, Saxenda, Qsymia, Contrave, and, where clinically appropriate for diabetic indications, Ozempic or Mounjaro.

Medications are prescribed only when clinically appropriate based on the physician's independent medical judgment. Enrollment in this membership does not guarantee that any medication will be prescribed, approved by insurance, or produce any particular result. Individual results vary.

The Member selects a commitment term with the corresponding monthly rate:

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Medical Weight Management Agreement

Commitment	Monthly Rate	If Cancelled Early
12-month commitment	$99 / month	Rate adjusts to applicable shorter-term rate
6-month commitment	$129 / month	Rate adjusts to 3-month rate
3-month commitment	$149 / month	No adjustment (shortest term)

Membership fees are billed monthly to the payment method on file, beginning on the start date and recurring on the same day each month for the duration of the commitment term.

If the Member cancels before completing the selected commitment term, the discounted rate is forfeited and the Member's rate is retroactively adjusted to the applicable shorter-term rate for the months already used. The Member agrees to pay the difference between the discounted rate received and the adjusted rate. For example, a Member on the 12-month tier ($99/month) who cancels after 5 months will have their rate adjusted to the 6-month rate ($129/month), and will owe the difference of $30 per month for the 5 months used ($150 total).

The following are billed separately and are NOT included in the membership fee:

• Initial video visit — billed to the Member's insurance, or cash-pay at $178
• Follow-up video visits (when clinically indicated) — billed to insurance, or cash-pay at $145
• Medications — covered by the Member's insurance (subject to copay) or, if denied, through manufacturer cash-pay programs
• Laboratory tests and any imaging — billed separately and may be covered by insurance

The Practice will submit prior authorization requests to the Member's insurance as part of the membership. If coverage is approved, the Member is responsible for applicable copays. If coverage is denied, the Practice will discuss manufacturer cash-pay programs and savings options. The Practice does not guarantee insurance approval or any particular medication cost.

• Provide accurate, complete medical history and disclose all medications and conditions
• Maintain a valid payment method on file
• Attend the initial video visit and any clinically indicated follow-up visits
• Use the HIPAA-compliant secure messaging platform for all clinical communication
• Report side effects, adverse reactions, or concerning symptoms promptly
• Complete recommended laboratory monitoring as directed
• Not rely on the membership for emergency care — call 911 in an emergency
• Maintain an established primary care provider for general medical care

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Medical Weight Management Agreement

This Agreement begins on the start date and continues for the selected commitment term, billed monthly. After the commitment term, membership continues month-to-month and may be cancelled with 30 days' written notice. Cancellation before the end of the commitment term triggers the rate adjustment described in Section 4.3.

The Practice may terminate this Agreement for non-payment, abusive conduct, clinical inappropriateness of continued membership, or any reason with 30 days' notice. The Practice may decline to continue prescribing if clinically inappropriate.

This membership is NOT health insurance. It does not cover the cost of medical services or medications and does not satisfy any requirement to maintain health insurance. The Member should maintain comprehensive health insurance independently.

The membership fee is a retainer for physician medical management services and is not prepaid medical care. This Agreement is not regulated by the California Department of Managed Health Care and is not a Knox-Keene licensed health plan.

Care is delivered via telehealth in accordance with California Business and Professions Code Section 2290.5. The Member consents to telehealth care, subject to a separate Telehealth Informed Consent form. All clinical communication occurs through the Practice's HIPAA-compliant secure messaging platform.

Standard SMS text messages and email are NOT HIPAA-compliant and are NOT encrypted. The Practice will not send protected health information by standard text or email. The Member agrees to use only the secure messaging platform for clinical communication.

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Medical Weight Management Agreement

This section is a distinct informed consent for telehealth care. It is provided in accordance with
California Business and Professions Code Section 2290.5 and requires the Member's separate
acknowledgment and signature at the end of this section.

Telehealth is the delivery of health care services using interactive audio, video, or data communications,
including the asynchronous (store-and-forward) transmission of medical information that the physician
reviews at a later time. The Member's care under this membership will be delivered primarily through
asynchronous secure messaging, supplemented by video visits when clinically indicated and an initial
video visit to establish the patient-physician relationship.

The Member specifically understands and consents that a substantial portion of their care will be
delivered asynchronously. This means the Member may submit information, questions, data (such as
weight logs or glucose readings), and concerns through the secure messaging platform, and the
physician will review and respond within a reasonable timeframe rather than in real time. The Member
understands that asynchronous care is not appropriate for urgent or emergency situations.

Telehealth offers improved access to specialty care, convenience, reduced travel, and the ability to
receive ongoing management between visits. It allows the Member to receive endocrinology and weight
management care from anywhere in California.

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

• The physician cannot perform a hands-on physical examination, which may limit the evaluation in
  certain circumstances
• Technology failures, delays, or interruptions may occur
• In rare cases, information transmitted may be insufficient to allow appropriate clinical decision-
  making, requiring an in-person visit
• Despite reasonable security measures, no electronic transmission of information is completely
  secure, and there is a small risk of breach of privacy
• The physician may determine that telehealth is not appropriate for a particular concern and that
  in-person evaluation is necessary

The Member understands that they may withdraw consent to telehealth at any time without affecting their
right to future care, and may request an in-person referral or care at any time. The Member has the right
to ask questions about telehealth care and to have those questions answered. The same standards of
care, confidentiality, and privacy protections that apply to in-person care apply to telehealth care.

The Member understands that this telehealth membership is NOT for emergencies. In a medical
emergency, the Member must call 911 or proceed to the nearest emergency room. The secure
messaging platform is not monitored continuously and must not be used for urgent or life-threatening
situations.

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Medical Weight Management Agreement

Telehealth Consent Acknowledgment: By signing below, the Member acknowledges that they have read and understood this Telehealth Informed Consent, have had the opportunity to ask questions, and consent to receiving care via telehealth, including asynchronous care, as described above.

The Practice's liability for any claim related to membership services (distinct from medical malpractice claims, governed by California law) shall not exceed the total membership fees paid in the preceding twelve months. This Agreement is governed by California law. Disputes shall be resolved first by good-faith negotiation, then by binding arbitration in San Diego County, except either party may seek injunctive relief in court.

This Agreement, together with the GLP-1 informed consent, constitutes the entire agreement. It may be amended only in writing, except the Practice may modify services with 30 days' notice. If any provision is unenforceable, the remainder stays in effect.

Attorney note: Review arbitration clause, liability limitation, early-termination rate-adjustment mechanism, and telehealth informed consent language for enforceability under California consumer protection and medical practice law.

By signing below, the Member acknowledges they have read, understood, and agree to this Agreement, including the commitment term and early-termination rate adjustment (Section 4.3), the separate billing of visits and medications (Section 4.4), the FDA-approved-only medication policy (Section 3.2), the Telehealth Informed Consent (Section 9), and the disclosure that this membership is not insurance (Section 7).

Physician signature - Jamil Alkhaddo, MD

Confidential North County Endocrinology Associates www.ncendocrinology.com

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