Terms of Service

PATIENT ADVOCACY SERVICES USER AGREEMENT

ModRN Health, LLC

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY MODRN HEALTH, LLC AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY

The benefits provided to you by your employer include patient health advocacy services provided by ModRN Health, LLC (“ModRN Health”). ModRN Health and your employer have entered into an agreement that allows you to utilize services provided by ModRN Health. Please take a minute to ensure that you understand the terms and conditions of our relationship by reading this important information, which includes certain limitation of liability and indemnification provisions applicable to your use of ModRN Health services. This ModRN Health User Agreement (“Agreement”) governs the relationship between ModRN Health and users of its health advocacy services (“Services”).

This Agreement expressly includes the terms of the HIPAA Notice of Privacy Practices (“Privacy Notice”) provided to you and included on ModRN Health’s website at modrnhealth.com. The Privacy Notice discloses ModRN Health’s practices regarding the collection and use of your personal information. By agreeing to the terms of this Agreement, you are also agreeing to the terms of our Privacy Notice and consenting to the use and disclosure of information provided to us as outlined therein.

SERVICES PROVIDED BY MODRN HEALTH

ModRN Health provides clinical personalized coordination and support to better engage and guide individuals and families through their health care journey, helping them manage their healthcare.

ModRN Health’s patient care advocates assist clients in understanding care and treatment options, to facilitate informed decision-making. Patient care advocates communicate to a client how the healthcare system functions and the role of patients, healthcare providers, and payers (third-party insurance, Medicare, Medicaid, etc.) in the system. The advocate helps a client navigate the complexities of the system which may include treatment options, care transitions, treatment compliance, provider collaboration and communication, identification of other community resources, prescription drug costs and coverage, health insurance, and billing.

MODRN HEALTH DOES NOT PROVIDE MEDICAL OR NURSING TREATMENT

ModRN Health provides administrative, informational and referral type services, through its patient care advocates. ModRN Health does NOT give medical advice or provide medical or nursing treatment, testing, diagnoses, prescriptions, prognoses, hands-on clinical care, or any healthcare directives. It is not health insurance, direct primary care, or concierge medicine. All of your medical and nursing treatment will be provided by your own independent healthcare practitioners and not by ModRN Health or its advocates.

Patient care advocates are committed to helping clients and client communities make informed choices and access resources. Advocates will not prescribe specific treatment, provide medical diagnosis, or perform hands-on clinical care of any type, even if they possess clinical credentials.

ModRN Health may assist clients in organizing and managing their health and billing records and may provide relevant information and materials for informational and education purposes. Such information and/or materials are not intended to serve as professional medical advice, diagnosis or treatment and should not serve as a substitute for the advice of a physician.

Patient care advocates will guide and assist clients in medical decision-making but at no time will make decisions about health or medical care or payment for medical services on their behalf. ModRN Health’s services are not a substitute for professional medical treatment. Clients should always seek the advice of their physicians or other qualified medical and/or other health care providers regarding medical conditions.

YOUR OBLIGATIONS

ModRN Health can provide patient care advocacy only with your cooperation in providing accurate and up-to-date health- and healthcare-related information to it. You may be asked to provide certain personal and personal health information to ModRN Health to assist it in providing Services. By agreeing to the terms of this Agreement, you are confirming that you will provide a complete and accurate account of your medical history and conditions including medications to ModRN Health.

DISCLAIMER OF LIABILITY

By signing below, you agree that you are voluntarily and unequivocally waiving any potential claim against ModRN Health for failing to diagnose, treat, or prevent any illness. In consideration of your participation in ModRN Health’s services, you accept all risk to your health, including injury or death, and you hereby release ModRN Health, on your behalf and on behalf of your personal representatives, estate, heirs, next of kin, and assigns, from any and all costs, claims, causes of action and damages arising from any and all illness or injury to your person, including your death, that may result from or occur as a result of your participation in ModRN Health’s Services described herein, whether caused by negligence or otherwise.

You understand that any healthcare decisions and actions you may make while using ModRN Health’s Services are undertaken of your own free will. You acknowledge that you have read the above release and waiver of liability, and fully understand its contents and voluntarily agree to the terms and conditions stated.

YOU ACKNOWLEDGE THAT YOU HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTOOD IT TO BE A FULL AND FINAL RELEASE OF ALL COSTS, CLAIMS, CAUSES OF ACTION AND DAMAGES OF ANY KIND ARISING FROM OR IN CONNECTION WITH MODRN HEALTH’S SERVICES.

INDEMNIFICATION

You agree to defend, indemnify and hold harmless ModRN Health and its officers, directors, employees, agents, representatives, successors and assigns, against, from and in respect of all Indemnifiable Damages. For this purpose, the term “Indemnifiable Damages” means the aggregate of all losses, liabilities, costs, deficiencies, damages and expenses (including attorney’s fees and court costs) arising as a result of or in connection with any misrepresentation or breach of warranty or non-fulfillment of any obligation of you under this Agreement or negligence or willful misconduct. You will indemnify ModRN Health against any claim arising out of, related to, or as a result of ModRN Health’s compliance with a specific direction you make.

SEVERABILITY

If any term or provision of this Agreement is invalid, illegal or unenforceable in any jurisdiction, such invalidity, illegality or unenforceability shall not affect any other term or provision of this Agreement or invalidate or render unenforceable such term or provision in any other jurisdiction.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the internal laws of the State of Kansas without giving effect to any choice or conflict of law provision or rule (whether of the State of Kansas or any other jurisdiction). You agree that, in the event that you might make any claim against ModRN Health for negligence, breach of contract, or any other claim relating to the provision of services described herein, that claim shall be brought exclusively in the District Court of Johnson County, Kansas and not in any other jurisdiction, venue, or court.

OUR OBLIGATIONS:

Although ModRN Health, LLC is not a “covered entity” under the law, we abide by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Under HIPAA, we are required to:

* Maintain the privacy of protected health information

* Give you this notice of our legal duties and privacy practices regarding health information about you

* Notify affected individuals following a breach of unsecured protected information

* Follow the terms of our notice that is currently in effect

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION:

The following describes the ways we may use and disclose health information that identifies you (“Health Information”). Except for the purposes described below, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer.

For Treatment. We may use and disclose Health Information to provide patient care advocacy to you with regard to treatment-related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.

For Payment. We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment.

For Health Care Operations. We may use and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that our clients receive quality care and to operate and manage our office. For example, we

may use and disclose information to evaluate and improve your care and/or to help us decide what additional services we should offer our clients.

Appointment Reminders, Treatment Alternatives and Health Related Benefits and

Services. We may use and disclose Health Information to contact you to remind you that you have an appointment with a provider. We also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.

Research. Under certain circumstances, we may use and disclose Health Information for research purposes.

SPECIAL SITUATIONS:

As Required by Law. We will disclose Health Information when required to do so by international, federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.

Business Associates. We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, we may release Health Information as required by military command authorities.

Workers’ Compensation. We may release Health Information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be

using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we

believe a client has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.

Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties.

National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

YOUR CHOICES:

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT:

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care. If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

Disaster Relief. We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES:

The following uses and disclosures of your Protected Health Information will be made

only with your written authorization:

1. Uses and disclosures of Protected Health Information for marketing purposes; and

2. Disclosures that constitute a sale of your Protected Health Information; and

3. Most sharing of psychotherapy notes.

Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose Protected Health Information under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.

YOUR RIGHTS:

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Right to Inspect and Copy or to an Electronic Copy of Electronic Medical Records. You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you, including billing records. To inspect and copy this Health Information, you must make your request, in writing, to [NAME OF CONTACT AND EMAIL ADDRESS] We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the

denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request. If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.

Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. We will accept or deny a request as permitted or required by law. To request an amendment, you must make your request, in writing, to [NAME OF CONTACT AND EMAIL ADDRESS] We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Right to Request Confidential Communications. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. To request confidential communications, please make your request in writing and specify how or where you wish to be contacted. We will say “yes” to all reasonable requests.

Right to Request Restrictions on Sharing or Using Information. You may ask us to restrict or limit what we use or share. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Right to an Accounting of Disclosures. You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Right to a Paper Copy of this Notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly upon written request. It is also available at our website.

Right to Choose Someone to Act for You. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

Right to File a Complaint if You Feel Your Rights are Violated. You may complain if you feel we have violated your privacy rights by contacting us directly at:

Contact: Liz Dagel

ModRN Health, LLC

7500 College Blvd, Fifth Floor

info@modrnhealth.com

913.831.8812

Effective Date: 9.01, 2018

If you have any questions about this notice, please contact

Liz Dagel

ModRN Health, LLC

7500 College Blvd, Fifth Floor

info@modrnhealth.com

913.831.8812

You may also (or alternatively) file a complaint with the U.S. Department of Health and Human Services Office, Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling 1-877-696-6775.

We will not retaliate against you for filing a complaint.

Changes to the Terms of this Notice

We can change the terms of this notice, and any changes will apply to all information we

have about you currently as well as information we receive in the future. The new notice will be available upon request, in our office, and on our website.