New Jersey Pure Wellness Medical 166 Paris Ave Northvale, NJ 07647
+1 855-679-7873 (Northvale)
1 844-335--7873 (Florida)
info@purewellnessmedical.com
Below you will find all published and applicable Pure Wellness Medical ("PWM") Policies & Terms ("P&T"), which are all incorporated by reference in the Client Agreement, which all Clients are required to execute prior to any consultations or treatments.
The PWM P&T's as published below as effective as of December 26, 2021.
Please be sure to read the below PWM P&T's in conjunction with your Client Agreement when reviewing and analyzing the terms of the relationship between the Client and PWM.
For your convenience, and ease of navigation, we have offered the following hyperlinks, which will take you to your desired location, to review the existing PWM P&T.
As stated in your Client Agreements, the Client Agreement is a contract between you and Pure Wellness Medical ("PWM"), which governs the terms and conditions of your relationship with PWM. This applies to all PWM accounts. By execution of the Client Agreement, or by the Clients continued use of the services provided by PWM, the Client agrees that they are a resident of the United States, and you are at least 18 years old, or the age of majority in your state of residence. If the Client a business client, the business must be organized in, operating in, or a resident of, the United States or one of its territories, must be in good standing, and must function in compliance with all laws, regulations and governmental policies and procedures.
By becoming a client of PWM, or by using the PWM services, you agree to comply with all of the terms and conditions of this Client Agreement, including all other agreements identified below, and any upcoming changes, of which you will be notified. These terms include an agreement to resolve disputes by arbitration on an individual basis.
Please read carefully all of the terms and conditions of the Client Agreement, of each of these Policies & Terms, and each of the individual agreements that apply to you.
Consent Form To Participate In A Research Study
HIPAA Notice of Privacy Practices & Policy
Hormone Replacement Therapy Consent
Electronic Communications Delivery Policy
These Terms & Conditions govern your use of our online interfaces and properties (e.g., websites and mobile applications) owned and controlled by Pure Wellness Medical, P.C. ("Pure Wellness Medical") regarding online telehealth medical consultations and secure messaging between Pure Wellness Medical physicians, if applicable other healthcare professionals (individually the "Provider" and collectively the "Providers") and consumers / clients / clients. The professional medical services (which are provided by Pure Wellness Medical) any physical location, guidance delivered through the website platforms ("Site") and the non-clinical Site services (which are provided by Pure Wellness Medical) are collectively referred to in this Terms & Conditions as the "Services". The terms "you" and "your" means you, your dependent(s) if any, and any other person accessing your Pure Wellness Medical Account.
Your acceptance of, and compliance with, these Terms & Conditions is a condition to your use of the Site and Services and purchase of Products. By clicking "accept", you acknowledge that you have read, understand, and accept all terms and conditions contained within these Terms & Conditions, the Notice of Privacy Practices provided to you by Pure Wellness Medical, and our Privacy Policy. If you do not agree to be bound by these terms, you are not authorized to access or use this Site or Services; promptly exit this Site.
NOTE THAT THESE TERMS & CONDITIONS SERVE AS THE CONTRACTUAL OBLIGATIONS AND SPECIFICATIONS BETWEEN YOU, THE USER, AND PURE WELLNESS MEDICAL. BY VISITING AND USING THE WEBSITE, YOU AGREE TO THE TERMS & CONDITIONS HEREIN.
Binding Arbitration. These Terms & Conditions provide that all disputes between you and Pure Wellness Medical that in any way relate to these Terms & Conditions or your use of the Site will be resolved by BINDING ARBITRATION. ACCORDINGLY, YOU AGREE TO GIVE UP YOUR RIGHT TO GO TO COURT (INCLUDING IN A CLASS ACTION PROCEEDING) to assert or defend your rights under these Terms & Conditions. Your rights will be determined by a NEUTRAL ARBITRATOR and NOT a judge or jury and your claims cannot be brought as a class action. Please review the Section below entitled Dispute Resolution; Arbitration Agreement the details regarding your agreement to arbitrate any disputes with Pure Wellness Medical.
You agree that information provided by you in connection with the Services and Site shall be governed by the Pure Wellness Medical Privacy Policy, which is hereby incorporated and made a part of this Agreement. You agree that information provided by you in connection with the Services shall also be governed by the Pure Wellness Medical Notice of Privacy Practices, and is hereby incorporated and made a part of this Agreement.
2. Services Provided - No Medical Care or Advice by Pure Wellness Medical Unless Expressly Agreed To By The Parties.
We offer an online communication platform for Providers and their clients to connect via the Site through the use of synchronous and asynchronous telecommunications technologies. The Site facilitates communication between clients and Providers.
Through its Site, website and any applications (if applicable) Pure Wellness Medical does not provide medical advice or care. Pure Wellness Medical contracts with Pure Wellness Medical, which serves as an independent, physician-owned medical group who provide a variety of clinical and telehealth services. Through Pure Wellness Medical- Providers deliver clinical services via the Pure Wellness Medical platform to their clients. Providers are independently contracted or employed by the Pure Wellness Medical. Providers are not contracted or employed by Pure Wellness Medical. The Providers, and not Pure Wellness Medical, are responsible for the quality and appropriateness of the care they render to you. For clarification, if you are NOT a client of Pure Wellness Medical, and if you do NOT have a contractual agreement establishing a relationship, then your use of the Site, website and any applications (if applicable) is only for informational and educational purposes, and nothing else.
In the event that any Pure Wellness Medical works with any third party Providers, such Providers are independent of Pure Wellness Medical and are merely using the Site as a way to communicate with you. Any information or advice received from a Provider comes from them alone, and not from Pure Wellness Medical. Your interactions with the providers via the Site are not intended to take the place of your relationship with your regular health care practitioners or primary care physician. Neither Pure Wellness Medical, nor any of its subsidiaries or affiliates or any third party who may promote the Site or Service or provide a link to the Service, shall be liable for any professional advice obtained from a Provider via the Site or Service, nor any information obtained on the Site. Pure Wellness Medical does not recommend or endorse any specific Providers, tests, physicians, medications, products, or procedures. You acknowledge that your reliance on any Providers or information delivered by the Providers via the Site or Service is solely at your own risk and you assume full responsibility for all risks associated herewith.
Pure Wellness Medical does not make any representations or warranties about the training or skill of any Providers who deliver services via the Site or Service. You will be provided with available Providers based solely on the information you submit to the Site. You are ultimately responsible for choosing your particular Provider.
The content of the Site and the Services, including without limitation, text, copy, audio, video, photographs, illustrations, graphics, and other visuals, is for informational purposes only and does not constitute professional medical advice, diagnosis, treatment, or recommendations of any kind by Pure Wellness Medical. You should always seek the advice of your qualified health care professionals with any questions or concerns you may have regarding your individual needs and any medical conditions. All information provided by Pure Wellness Medical, or in connection with any communications supported by Pure Wellness Medical, is intended to be for general information purposes only, and is in no way intended to create a provider-patient relationship as defined by state or federal law. While Pure Wellness Medical facilitates your selection of, and communications with, Providers, Pure Wellness Medical does not provide medical services, and the doctor-patient relationship is between you and the Pure Wellness Medical- Medical Provider you select.
Not for Emergencies
IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL "911" IMMEDIATELY.
Pure Wellness Medical's Site and Services are not for medical emergencies or urgent situations. You should not disregard or delay to seek medical advice based on anything that appears or does not appear on the Site. If you believe you have an emergency, call 9-1-1 immediately
You should seek emergency help or follow up care when recommended by a Provider or when otherwise needed. You should continue to consult with your primary provider and other healthcare professionals as recommended. Always seek the advice of a physician or other qualified healthcare provider concerning questions you have regarding a medical condition and before stopping, starting, or modifying any treatment or modification.
By using the Services, you acknowledge the potential risks associated with telehealth services. These include but are not limited to the following: information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical or health care decision making by the Provider; delays in evaluation or treatment could occur due to failures of electronic equipment; a lack of access to your medical records may result in adverse drug interactions or allergic reactions or other judgment errors; although the electronic systems we use incorporate network and software security protocols to protect the privacy and security of health information, those protocols could fail causing a breach of privacy of your health information.
Other than what is expressly stated on the Site platform, Pure Wellness Medical does not endorse any specific medication, pharmacy, or pharmacologic product. If a Provider prescribes a medication, he/she will limit supply based upon state regulations and will only prescribe a medication as determined in his/her own discretion and professional judgment. There is no guarantee a prescription will be written. Providers do not prescribe DEA controlled substances or scheduled medications, or certain other drugs which may be harmful because of their potential for abuse. Providers reserve the right to deny care for actual or potential misuse of the Services.
You agree that any prescriptions that you acquire from a Provider will be solely for your personal use. You agree to fully and carefully read all provided product information and labels and to contact a physician or pharmacist if you have any questions regarding the prescription. Pure Wellness Medical fully honors patient freedom of choice and, if you receive a prescription for a medication, you always have the option to instruct Pure Wellness Medical to transmit that prescription to the pharmacy of your choice.
Pure Wellness Medical is not Your insurers. The Services are not insurance products, and the amounts you pay to Pure Wellness Medical are not insurance premiums. If you desire any type of health or other insurance, you will need to purchase such insurance separately.
3. Availability of Services
Pure Wellness Medical operates subject to state and federal regulations, and the Services may not be available in your state. You represent that you are not a person barred from enrolling for and/or receiving the Services under the laws of the United States or other applicable jurisdictions in which you may be located. Access to and use of the Site and/or the Services is limited exclusively to users located in States within the United States where the Services are available. Services are not available to users located outside the United States. Accessing the Site or Services from jurisdictions where content is illegal, or where we do not offer Services, is prohibited.
4. Ordering and Purchasing of Services or Products
Your placement of an order does not necessarily ensure that we will accept your order. We may require additional information regarding your order if you have not provided all the information required by us to completed. Once a properly completed order and authorization of your form of payment is received, we will process your order and Product for shipment. If, for some reason, we determined that we cannot ship your Product(s) within thirty (30) days following our receipt of a properly completed order, we will cancel your order and advise you of such action. We do not accept orders from dealers, wholesalers, or other customers who intend to resell items offered on our Site.
Typographical Errors and Incorrect Pricing
In the event a Product or Service is listed at an incorrect price due to typographical error or error in pricing information received from a third party, we shall have the right to refuse or cancel any orders placed for the Products and/or Service(s) listed at the incorrect price. We shall have the right to refuse or cancel any such orders whether or not the order has been confirmed and your credit or debit card charged. If your credit or debit card has already been charged for the purchase and your order is canceled, we will promptly issue a credit to your credit or debit card account in the amount of the charge.
Risk of Loss
All Products purchased from our Site are delivered to shipment carriers. The risk of loss and title for such Products pass to you when they are delivered to the carrier.
Return Policy
You may return Products in accordance with our Returns Policy posted on our Site.
You can purchase services on the Site. We accept credit and debit cards issued by U.S. banks. If a credit card account is being used for a transaction, Pure Wellness Medical may obtain preapproval for an amount up to the amount of the payment. If you enroll to make recurring payments automatically, all charges and fees will be billed to the credit card you designate during the setup process. If you want to designate a different credit card or if there is a change in your credit card, you must change your information online. This may temporarily delay your ability to make online payments while we verify your new payment information.
You represent and warrant that if you are making online payments that (a) any credit card, debit card and bank account information you supply is true, correct, and complete, (b) charges incurred by you will be honored by your credit/debit card company or bank, (c) you will pay the charges incurred by you in the amounts posted, including, without limitation, any applicable taxes, and (d) you are the person in whose name the card was issued and you are authorized to make a purchase or other transaction with the relevant credit card and credit card information.
5. Eligibility; Site Access, Security and Restrictions; Passwords
In order to access the Site and the Services, you represent and warrant that you are older than 18 years old. You agree to fully, accurately, and truthfully create your Pure Wellness Medical Account ("Account"), including but not limited to your name, mailing address, phone number, email address, and password, which become your Pure Wellness Medical ID and credentials. The Pure Wellness Medical ID and/or credentials are personal to you, and you are solely responsible for maintaining the confidentiality of your Pure Wellness Medical ID and/or credentials, and for all activities that occur under such Pure Wellness Medical ID and/or credentials. You agree to prohibit anyone else from using your Pure Wellness Medical ID and/or credentials and agree to immediately notify Pure Wellness Medical of any actual or suspected unauthorized use of your Pure Wellness Medical ID and/or credentials or other security concerns of which you become aware. Your access to the Site may be revoked by Pure Wellness Medical at any time with or without cause.
You are prohibited from violating or attempting to violate the security of the Site, including, without limitation: (a) accessing data not intended for such user or logging onto a server or an account which the user is not authorized to access; (b) attempting to probe, scan, or test the vulnerability of a system or network or to breach security or authentication measures without proper authorization; or (c) accessing or using the Site or any portion thereof without authorization, in violation of these Terms & Conditions or in violation of applicable law.
You may not use any scraper, crawler, spider, robot, or other automated means of any kind to access or copy data on the Site, deep-link to any feature or content on the Site, bypass our robot exclusion headers, or other measures we may use to prevent or restrict access to the Site. Violations of system or network security may result in civil or criminal liability. Pure Wellness Medical will investigate occurrences that may involve such violations and may involve, and cooperate with, law enforcement authorities in prosecuting users who are involved in such violations. You agree not to use any device, software, or routine to interfere or attempt to interfere with the proper working of this Site or any activity being conducted on this Site.
6. Electronic Communications
When you use the Site or Services, or send e-mails, messages, and other communications from your desktop or mobile device to us, you are communicating with us electronically. You consent to receive communications from us electronically. You agree that (a) all agreements and consents can be signed electronically and (b) all notices, disclosures, and other communications that we provide to you electronically satisfy any legal requirement that such notices and other communications be in writing. Pure Wellness Medical may contact you by telephone, mail, or email to verify your Account information. Pure Wellness Medical may request further information from you and you agree to provide such further information to ensure that you have not fraudulently created your Account. If you do not provide this information in the manner requested within 14 days of the request, we reserve the right to suspend, discontinue, or deny your access to and use of the Site and the Services until you provide the information to us as requested.
7. Consent to Receive Calls
By providing your phone number, you are agreeing to be contacted by or on behalf of Pure Wellness Medical at the number you have provided, including calls and text messages, to receive informational, Services related (e.g., progress tracking, prescription fulfillment, appointment reminders, etc.) and marketing communications relating to the Site and Services. You can opt-out of receiving further calls and text messages from us by going to the following link opt-out. Please note, that by withdrawing your consent, some Site features and certain Services may no longer be available to you.
8. Ownership Of The Site And Related Materials; Additional Restrictions
All pages within this Site and any material made available for download are the property of Pure Wellness Medical, or its licensors or suppliers, as applicable. The Site is protected by United States and international copyright and trademark laws.
Subject to these Terms & Conditions and the payment of all applicable fees, Pure Wellness Medical grants you a revocable, non-transferable (except as provided below), personal, nonexclusive license to use the object code version of the Site. All rights not expressly granted to you in these Terms & Conditions are reserved and retained by Pure Wellness Medical or its licensors, suppliers, publishers, rights holders, or other content providers. Neither the Site and Services, nor any part of the Site and Services, may be reproduced, duplicated, copied, sold, resold, visited, or otherwise exploited for any commercial purpose without express written consent of Pure Wellness Medical. You may not frame or utilize framing techniques to enclose any trademark, logo, or other proprietary information (including images, text, page layout, or form) of Pure Wellness Medical without express written consent. You may not use any meta tags or any other "hidden text" utilizing Pure Wellness Medical's name or trademarks without the express written consent of Pure Wellness Medical. You may not misuse the Site or Services. You may use the Site and Services only as permitted by law. The content of the Site, including without limitation the files, documents, text, photographs, images, audio, and video, and any materials accessed through or made available for use or download through this Site may not be copied, distributed, modified, reproduced, published, or used, in whole or in part, except for purposes authorized or approved in writing by Pure Wellness Medical. You may not frame or utilize framing techniques to enclose, or deep linking to, any name, trademarks, service marks, logo, content, or other proprietary information (including, without limitation, images, text, page layout, or form) of Pure Wellness Medical without our express written consent.
9. No Users Under 18 Years Old
The Site and Services are only for users of the age of 18. If you are under the age of 18, please do not attempt to register with us at this Site or provide any personal information about yourself to us. If we learn that we have collected personal information from someone under the age of 18, we will promptly delete that information. If you believe we have collected personal information from someone under the age of 18, please contact us at info@purewellnessmedical.com or call us at (855) 679-7873
10. Accuracy of Information; Functionality
Although Pure Wellness Medical attempts to ensure the integrity and accurateness of the Site and Service descriptions, it makes no representations, warranties, or guarantees whatsoever as to the correctness or accuracy of the Site, Service descriptions and other content on the Site. It is possible that the Site could include typographical errors, inaccuracies or other errors, and that unauthorized additions, deletions, and alterations could be made to the Site by third parties. In the event that an inaccuracy arises, please inform Pure Wellness Medical so that it can be corrected. Information contained on the Site may be changed or updated without notice. Additionally, Pure Wellness Medical shall have no responsibility or liability for information or content posted to the Site from any non- Pure Wellness Medical affiliated third party.
Pure Wellness Medical reserves complete and sole discretion with respect to the operation of the Site and the Services. We may withdraw, suspend, or discontinue any functionality or feature of the Site or the Services among other things. We are not responsible for transmission errors, corruption, or compromise of information carried over local or interchange telecommunications carrier. We are not responsible for maintaining information arising from use of the Site or with respect to the Services. We reserve the right to maintain, delete, or destroy all communications or information posted or uploaded to the Site or the Services in accordance with our internal record retention and/or destruction policies.
11. Links to Other Sites
Pure Wellness Medical makes no representations whatsoever about any other website that you may access through this Site. When you access a non- Pure Wellness Medical site, please understand that it is independent from Pure Wellness Medical, and that Pure Wellness Medical has no control over the content on that website. In addition, a link to a non- Pure Wellness Medical website does not mean that Pure Wellness Medical endorses or accepts any responsibility for the content, or the use, of the linked site. It is up to you to take precautions to ensure that whatever you select for your use or download is free of such items as viruses, worms, Trojan horses, and other items of a destructive nature. If you decide to access any of the third-party sites linked to this Site, you do this entirely at your own risk.
12. User Information
If you submit, upload, post, or transmit any health information, medical history, conditions, problems, symptoms, personal information, consent forms, agreements, requests, comments, ideas, suggestions, information, files, videos, images, or other materials to us or our Site ("User Information"), you agree not to provide any User Information that (a) is false, inaccurate, defamatory, abusive, libelous, unlawful, obscene, threatening, harassing, fraudulent, pornographic, or harmful, or that could encourage criminal or unethical behavior, (b) violates or infringes the privacy, copyright, trademark, trade dress, trade secrets, or intellectual property rights of any person or entity, or (c) contains or transmits a virus or any other harmful component. You agree not to contact other Site users through unsolicited e-mail, telephone calls, mailings, or any other method of communication. You represent and warrant to Pure Wellness Medical that you have the legal right and authorization to provide all User Information to Pure Wellness Medical for use as set forth herein and required by Pure Wellness Medical.
Pure Wellness Medical may de-identify your information such that it is no longer considered protected health information or personally identifiable information. Pure Wellness Medical may disclose, aggregate, sell, or otherwise use such de-identified information to third parties for analytics, research, or other purposes.
You agree not to: (i) access the Site or use the Services in any unlawful way or for any unlawful purpose; (ii) post or transmit (1) a message under a false name, or (2) any data, materials, content, or information (including, without limitation, advice, and recommendations) (collectively "Information") which is (A) libelous, defamatory, obscene, fraudulent, false, or contrary to the ownership or intellectual property rights of any other person, or (B) contains or promotes any virus, worm, Trojan horse, time bomb, malware, or other computer programing or code that is designed or intended to damage, destroy, intercept, download, interfere, manipulate, or otherwise interrupt or expropriate the Site or the Services, personal information, software, equipment, servers, or Information or facilitate or promote hacking or similar conduct; (iii) impersonate or misrepresent your identity or falsely state or misrepresent your affiliation with a person or entity; (iv) tamper, hack, spoof, copy, modify, or otherwise corrupt the administration, security, or proper function of the Site or the Services; (v) use robots or scripts with the Site; (vi) attempt to reverse engine, reverse assemble, reverse compile, decompile, disassemble, translate, or otherwise alter, defraud, or create false results from any executable code, information on, or received by this Site; (vii) to have any antivirus or antispyware software running that is set to override the internet browser's cookies setting; (viii) incorrectly identify the sender of any message transmitted to Pure Wellness Medical; (ix) alter the attribution or origin of electronic mail, messages, or posting; (x) harvest or collect personal health information about any other individual who uses the Site or the Services; and (xi) infringe or facilitate infringement on any copyright, patent, trademark, trade secret, or other proprietary, publicity, or privacy rights of any party, including but not limited to, such rights of third parties.
You agree to defend, indemnify, and hold harmless Pure Wellness Medical, and the Providers from and against all third party claims, damages, and expenses (including, but not limited to, reasonable attorneys' fees) against or incurred by us arising out of any User Information you upload to or transmit through the Site or any breach of this Section 12.
13. Claims of Copyright Infringement
We disclaim any responsibility or liability for copyrighted materials posted on our Site. If you believe that your work has been copied in a manner that constitutes copyright infringement, please follow the procedures set forth below.
Pure Wellness Medical respects the intellectual property rights of others and expects its users to do the same. In accordance with the Digital Millennium Copyright Act ("DMCA"), we will respond promptly to notices of alleged infringement that are reported to Pure Wellness Medical's Designated Copyright Agent, identified below.
Notices of Alleged Infringement for Content Made Available on the Site
If you are a copyright owner, authorized to act on behalf of one, or authorized to act under any exclusive right under copyright, please report alleged copyright infringements taking place on or through our Site by sending us a notice ("Copyright Notice") complying with the following requirements.
1. Identify the copyrighted works that you claim have been infringed.
2. Identify the material or link you claim is infringing (or the subject of infringing activity) and that access to which is to be disabled, including at a minimum, if applicable, the URL of the link shown on the Site where such material may be found.
3. Provide your mailing address, telephone number, and, if available, email address.
4. Include both of the following statements in the body of the Copyright Notice:
"I hereby state that I have a good faith belief that the disputed use of the copyrighted material is not authorized by the copyright owner, its agent, or the law (e.g., as a fair use)."
"I hereby state that the information in this Copyright Notice is accurate and, under penalty of perjury, that I am the owner, or authorized to act on behalf of the owner, of the copyright or of an exclusive right under the copyright that is allegedly infringed."
5. Provide your full legal name and your electronic or physical signature.
Deliver this Notice, with all items completed, to our Copyright Agent:
Pure Wellness Medical, PC
Attn: Copyright Agent
199 Washington Street
Northvale, NJ 07647
Telephone: (855) 679-7873
Email: info@purewellnessmedical.com
14. Intellectual Property
With the exception of your electronic medical record, Pure Wellness Medical, as applicable, retain all right, title, and interest in and to the Site, the Services and any information, products, documentation, software, or other materials on the Site, and any patent, copyright, trade secret, trademark, service mark, or other intellectual property, or proprietary right in any of the foregoing, except for information on the Site licensed by Pure Wellness Medical (in that case, the license provider retains all right, title, and interest therein). The information available through the Site and the Services is the property of Pure Wellness Medical, as applicable. You agree not to store, copy, modify, reproduce, retransmit, distribute, disseminate, rent, lease, loan, sell, publish, broadcast, display, or circulate such information to anyone. Use, reproduction, copying, or redistribution of Pure Wellness Medical trademarks, service marks, and logos are strictly prohibited without the prior written permission of Pure Wellness Medical, as applicable. The immediately foregoing sentence also applies to any third-party trademarks, service marks, and logos posted on the Site. Nothing contained on the Site should be construed as granting, by implication, estoppel, waiver, or otherwise, any license or right to use any trademarks, service marks, or logos displayed on the Site without the written grant thereof by Pure Wellness Medical, or the third party owner of such trademarks, service marks, and/or logos. The Site may contain other proprietary notices and copyright information, the terms of which you agree to follow.
Pure Wellness Medical may delete any information provided by you that it deems in its sole discretion fraudulent, abusive, defamatory, obscene, or in violation of copyright, trademark, or other intellectual property or ownership right of any other person or entity.
15. CAN-SPAM Act and Telephone Consumer Protection Act Compliance
Pure Wellness Medical and Pure Wellness Medical are committed to being compliant with the Controlling the Assault of Non-Solicited Pornography and Marketing Act ("CAM-SPAM ACT") and the Telephone Consumer Protection Act ("TCPA"). You consent to receive text messages from us as set forth in Section 7, above (Consent to Receive Calls and Text Messages). Emails, newsletters, and text messages received from us are intended to fully comply with the CAM-SPAM ACT and the TCPA. In the event you receive an email or text message from us which you do not believe is fully compliant with the CAN-SPAM ACT or the TCPA, please contact us immediately at the address listed below under the section "How to Contact Us."
You shall not use or permit any of your employees, agents, or affiliates to market, promote, or solicit Pure Wellness Medical products or services in ways that would violate the CAN-SPAM ACT, the TCPA or any other laws. You shall not: (a) infringe on the rights of others; distribute chain letters or unsolicited bulk electronic mail ("spamming"); (b) propagate computer worms or viruses; (c) use a false identity; (d) attempt to gain unauthorized entry to any site or network; or (e) infringe copyrights, trademarks, or other intellectual property rights.
You further agree to comply with U.S. export laws concerning the transmission of technical data and regulated materials via the Internet. You agree to indemnify and hold Pure Wellness Medical and its affiliates harmless for any and all acts found or suspected to be in violation hereof. You shall indemnify and hold Pure Wellness Medical and its affiliates harmless against and from losses, damages, costs, and reasonable attorney fees incurred in defending or resolving any suits brought against Pure Wellness Medical or any of its affiliates by anyone arising out of any alleged violation of any anti-spamming rules, regulations, laws, statutes. Your Account will be terminated for any of the above infractions.
16. Disclaimer of Warranties
PURE WELLNESS MEDICAL DOES NOT WARRANT THAT ACCESS TO OR USE OF THE SITE WILL BE UNINTERRUPTED OR ERROR-FREE OR THAT DEFECTS IN THE SITE WILL BE CORRECTED. THIS SITE, INCLUDING ANY CONTENT OR INFORMATION CONTAINED WITHIN IT OR ANY SITE-RELATED SERVICE, IS PROVIDED "AS IS," WITH ALL FAULTS, WITH NO REPRESENTATIONS OR WARRANTIES OF ANY KIND, EITHER EXPRESSED OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, QUALITY OF INFORMATION, QUIET ENJOYMENT, AND TITLE/NON-INFRINGEMENT. PURE WELLNESS MEDICAL DOES NOT WARRANT THE ACCURACY, COMPLETENESS, OR TIMELINESS OF THE INFORMATION OBTAINED THROUGH THE SITE.
YOU ASSUME TOTAL RESPONSIBILITY AND RISK FOR YOUR USE OF THIS SITE, SITE-RELATED SERVICES, AND LINKED WEBSITES. PURE WELLNESS MEDICAL DOES NOT WARRANT THAT FILES AVAILABLE FOR DOWNLOAD WILL BE FREE OF VIRUSES, WORMS, TROJAN HORSES, OR OTHER DESTRUCTIVE PROGRAMMING. YOU ARE RESPONSIBLE FOR IMPLEMENTING PROCEDURES SUFFICIENT TO SATISFY YOUR NEEDS FOR DATA BACK UP AND SECURITY.
WARRANTIES RELATING TO PRODUCTS OR SERVICES OFFERED, SOLD, AND DISTRIBUTED BY PURE WELLNESS MEDICAL ARE SUBJECT TO SEPARATE WARRANTY TERMS AND CONDITIONS, IF ANY, PROVIDED BY PURE WELLNESS MEDICAL OR THIRD PARTIES WITH OR IN CONNECTION WITH THE APPLICABLE PRODUCTS OR SERVICES. PURE WELLNESS MEDICAL DOES NOT GUARANTEE THAT THROUGH USE OF OUR SERVICES ANY PRESCRIPTIONS WILL BE WRITTEN FOR YOU. PURE WELLNESS MEDICAL PROVIDERS DO NOT PRESCRIBE DEA CONTROLLED SUBSTANCES, SUCH AS THOSE CONTAINING OPIOIDS OR AMPHETAMINES. YOU ACKNOWLEDGE AND UNDERSTAND THAT THE USE OR MISUSE OF THE PRODUCTS OBTAINED THROUGH OUR SITE MAY RESULT IN UNDESIRABLE OR UNEXPECTED CONSEQUENCES. PURE WELLNESS MEDICAL DOES NOT ACCEPT ANY LIABILITY FOR THE CONSEQUENCES ARISING FROM THE APPLICATION, USE, OR MISUSE OF ANY PRODUCTS OR SERVICES CONTAINED ON OR MADE AVAILABLE THROUGH THE SERVICE, INCLUDING ANY INJURY OR DAMAGE TO ANY PERSON OR PROPERTY AS A MATTER OF NEGLIGENCE, OR OTHERWISE, INCLUDING YOUR FAILURE TO COMPLY WITH ANY WARNING LABELS ATTACHED TO THE PRODUCTS.
17. Limitation of Liability Regarding Use of Site
EXCEPT AS PROVIDED BY LAW, AND WITHOUT LIMITATION:
PURE WELLNESS MEDICAL SHALL NOT BE LIABLE FOR THE ACTS OR OMISSIONS OF PURE WELLNESS MEDICAL OR THE PROVIDERS. PURE WELLNESS MEDICAL AND ANY THIRD PARTIES MENTIONED ON THIS SITE ARE NEITHER RESPONSIBLE NOR LIABLE FOR ANY DIRECT, INDIRECT, INCIDENTAL, CONSEQUENTIAL, SPECIAL, EXEMPLARY, PUNITIVE, OR OTHER DAMAGES WHATSOEVER (INCLUDING, WITHOUT LIMITATION, THOSE RESULTING FROM LOST PROFITS, LOST DATA, OR BUSINESS INTERRUPTION) ARISING OUT OF OR RELATING IN ANY WAY TO THE SITE, SITE-RELATED SERVICES, CONTENT OR INFORMATION CONTAINED WITHIN THE SITE, AND/OR ANY LINKED WEBSITE, WHETHER BASED ON WARRANTY, CONTRACT, TORT, OR ANY OTHER LEGAL THEORY AND WHETHER OR NOT ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. YOUR SOLE REMEDY FOR DISSATISFACTION WITH THE SITE, SITE-RELATED SERVICES, AND/OR LINKED WEBSITES IS TO STOP USING THE SITE AND/OR THOSE SERVICES. TO THE EXTENT ANY ASPECTS OF THE FOREGOING LIMITATIONS OF LIABILITY ARE NOT ENFORCEABLE, THE MAXIMUM LIABILITY OF PURE WELLNESS MEDICAL TO YOU WITH RESPECT TO YOUR USE OF THIS SITE IS $500 (FIVE HUNDRED DOLLARS). YOU HEREBY AGREE TO WAIVE, TO THE FULLEST EXTENT PERMITTED BY LAW, ALL LAWS THAT LIMIT THE EFFICACY OF SUCH INDEMNIFICATIONS OR RELEASES.
18. No Third Party Rights
Unless expressly stated in the Terms & Conditions to the contrary, nothing herein is intended to confer any rights or remedies on any persons other than you, Pure Wellness Medical and their affiliates. Nothing in the Terms & Conditions is intended to relieve or discharge the obligation or liability of any third persons to you, Pure Wellness Medical, and its affiliates, nor shall any provision give any third parties any right of subrogation or action over against you, Pure Wellness Medical, and its affiliates.
Your use of the Site, website or any applications (if applicable) and any of the Services offered by Pure Wellness Medical may be immediately terminated and/or suspended without notice due to (a) a breach of these Terms & Conditions by You or any User, (b) the termination or expiration of any underlying Service Agreements between Pure Wellness Medical and You, and/or (c) a breach by any User of any obligations to Pure Wellness Medical with respect to any subscriptions that Pure Wellness Medical is providing to You in connection with any Pure Wellness Medical Services Agreements, or other written Agreements between the Parties. Further, You acknowledge and understand that (i) access to the Site, website or any applications used in Pure Wellness Medical may be suspended due to Your non-payment to Pure Wellness Medical for any Services, misconduct, improper behavior or other breach of any Agreements with Pure Wellness Medical. You hereby agree that in no case will any such termination or suspension give rise to any liability of Pure Wellness Medical to You for a refund or other compensation.
19. Assignment
You may not assign, transfer, or delegate the Terms & Conditions or any part thereof without Pure Wellness Medical's prior written consent. Pure Wellness Medical may freely transfer, assign, or delegate all or any part of the Terms & Conditions, and any rights or duties hereunder or thereunder. The Terms & Conditions will be binding upon and inure to the benefit of the heirs, successors, and permitted assignees of the parties.
20. Supplemental Terms Applicable to Providers
These supplemental terms apply to Providers in addition the other provisions of these Terms & Conditions. In the event of a conflict between the supplemental terms and any other terms herein, the supplemental terms shall prevail.
To be a healthcare provider using the Site (for purposes of this Section 20, "Provider" or "you") you must be a licensed physician, nurse practitioner, or healthcare professional contracted or employed by Pure Wellness Medical, and must agree to comply with all laws, medical board rules, and other rules and regulations applicable to you as a Provider or otherwise. Your relationship with the Pure Wellness Medical users (including, but not limited to, your Pure Wellness Medical clients) is directly between you and the patient. The patient will never have a physician-patient relationship with Pure Wellness Medical. Pure Wellness Medical does not practice medicine and offers no medical services. As set forth more fully below, Provider is solely responsible for all agreements, consents, notices, and other interactions with clients and other consumers. Without limiting the generality of the foregoing, Provider and Pure Wellness Medical is solely responsible for all billings and collections from clients and other consumers, and Pure Wellness Medical shall have no liability whatsoever to Provider with respect to any amounts owed by any patient or other consumer to Provider.
Through its Site, website and any applications (if applicable), Pure Wellness Medical does not provide any medical advice, legal advice, or representations in any way regarding any legal or medical issues associated with Provider, goods, or services offered by Provider, including but not limited to any compliance obligations or steps necessary to comply with any state or federal laws and regulations. Provider should seek legal counsel regarding any legal and compliance issues, and should not rely on any materials or content associated with the Services in determining Provider's compliance obligations under law. Provider and Pure Wellness Medical agree that Pure Wellness Medical is not providing, to Customer or anyone else, medical advice or legal advice.
Provider will use the Site and Services only in accordance with applicable standards of good medical practice. While software products such as the Site and Services can facilitate and improve the quality of service that Provider can offer clients, many factors, including but not limited to the provider/patient relationship can affect a patient outcome, and with intricate and interdependent technologies and complex decision-making it is often difficult or impossible to accurately determine what the factors were and in what proportion they affected an outcome. Provider shall be solely responsible for its use of the Site and Services, and the provision of medical services to Provider's clients. In this regard, Provider releases Pure Wellness Medical and waives any and all potential claims against Pure Wellness Medical as a result of Provider's use of the Site and Services, and the provision of services to Provider's clients.
As a result of the complexities and uncertainties inherent in the patient care process, Provider agrees to defend, indemnify and hold Pure Wellness Medical harmless from any claim by or on behalf of any patient of Provider, or by or on behalf of any other third party or person claiming damage by virtue of a familial or financial relationship with such a patient, which is brought against Pure Wellness Medical, regardless of the cause if such claim arises for any reason whatsoever, out of Provider's use or operation of the Site and Services. To the extent applicable, Provider will obtain Pure Wellness Medical's prior written consent to any settlement or judgment in which Provider agrees to any finding of fault of Pure Wellness Medical or defect in the Site or Services. Pure Wellness Medical will promptly notify Provider in writing of any claim subject to this indemnification, promptly provide Provider with the information reasonably required for the defense of the same, and grant to Provider exclusive control over its defense and settlement.
If you submit, upload, transmit, or post any consents, notices, advice, recommendations, comments, files, videos, images, or other materials to us or our Site ("Provider Content") or provide any Provider Content to clients or other consumers, you agree not to provide any Provider Content that (a) is defamatory, abusive, libelous, unlawful, obscene, threatening, harassing, fraudulent, pornographic, or harmful, or that could encourage criminal or unethical behavior, (b) violates or infringes the privacy, copyright, trademark, trade dress, trade secrets, or intellectual property rights of any person or entity, or (c) contains or transmits a virus or any other harmful component. Provider is solely responsible for obtaining all necessary agreements and consents from, and providing all required notices to, clients and other consumers. You agree not to contact other users through unsolicited e-mail, telephone calls, mailings, or any other method of communication. You represent and warrant to Pure Wellness Medical that you have the legal right and authorization to upload all Provider Content at the Site. Pure Wellness Medical shall have a royalty-free, irrevocable, transferable right and license to use the Provider Content however Pure Wellness Medical desires, including without limitation, to copy, modify, delete in its entirety, adapt, publish, translate, create derivative works from and/or sell and/or distribute such Provider Content and/or incorporate such Provider Content into any form, medium, or technology throughout the world. Pure Wellness Medical is and shall be under no obligation: (i) to maintain any Provider Content in confidence; (ii) to pay to you any compensation for any Provider Content; or (iii) to respond to any Provider Content.
Pure Wellness Medical does not regularly review Provider Content, but does reserve the right (but not the obligation) to monitor and edit or remove any Provider Content submitted to the Site. You grant Pure Wellness Medical the right to use the name that you submit in connection with any Provider Content. You agree not to use a false email address, impersonate any person or entity, or otherwise mislead as to the origin of any Provider Content. You are and shall remain solely responsible for the content of any Provider Content you post to the Site or provide to clients or other consumers. Pure Wellness Medical and its affiliates take no responsibility and assume no liability for any Provider Content submitted by you or any third party.
21. Dispute Resolution; Arbitration Agreement
We refer your attention to the Arbitration Agreement contained on the PWM website, for more details and specifics. In the event of any different terms as indicted herein, and in accordance to our Arbitration Agreement, the terms of the Arbitration Agreement, solely as it relates to the Arbitration, will control.
We will try work in good faith to resolve any issue you have with Site, including without limitation, Products and Services ordered or purchased through the Site, if you bring that issue to the attention of our customer service department. However, we realize that there may be rare cases where we may not be able to resolve an issue to a customer's satisfaction.
You and Pure Wellness Medical agree that any dispute, claim, or controversy arising out of or relating in any way to these Terms & Conditions or your use of the Site, including without limitation, Products and Services ordered or purchased through the Site, shall be determined by binding arbitration instead of in courts of general jurisdiction. Arbitration is more informal than bringing a lawsuit in court. Arbitration uses a neutral arbitrator instead of a judge or jury, and is subject to very limited review by courts. Arbitration allows for more limited discovery than in court, however, we agree to cooperate with each other to agree to reasonable discovery in light of the issues involved and amount of the claim. Arbitrators can award the same damages and relief that a court can award, but in so doing, the arbitrator shall apply substantive law regarding damages as if the matter had been brought in court, including without limitation, the law on punitive damages as applied by the United States Supreme Court. You agree that, by agreeing to these Terms & Conditions, the U.S. Federal Arbitration Act governs the interpretation and enforcement of this provision, and that you and Pure Wellness Medical are each waiving the right to a trial by jury or to participate in a class action. This arbitration provision shall survive termination of these Terms & Conditions and any other contractual relationship between you and Pure Wellness Medical.
If you desire to assert a claim against Pure Wellness Medical, and you therefore elect to seek arbitration, you must first send to Pure Wellness Medical, by certified mail, a written notice of your claim ("Notice"). The Notice to Pure Wellness Medical should be addressed to:
Pure Wellness Medical, PC
Attn: Legal Department
199 Washington Street
Northvale, NJ 07647
Telephone: (855)679-7873
Email: info@purewellnessmedical.com
If Pure Wellness Medical desires to assert a claim against you and therefore elects to seek arbitration, it will send, by certified mail, a written Notice to the most recent address we have on file or otherwise in our records for you. A Notice, whether sent by you or by Pure Wellness Medical, must (a) describe the nature and basis of the claim or dispute, and (b) set forth the specific relief sought ("Demand"). If Pure Wellness Medical and you do not reach an agreement to resolve the claim within 30 days after the Notice is received, you or Pure Wellness Medical may commence an arbitration proceeding or file a claim in small claims court. During the arbitration, the amount of any settlement offer made by Pure Wellness Medical or you shall not be disclosed to the arbitrator. You may download or copy a form Notice and a form to initiate arbitration from the American Arbitration Association at www.adr.org. If you are required to pay a filing fee, after Pure Wellness Medical receives notice at the Notice Address that you have commenced arbitration, it will promptly reimburse you for your payment of the filing fee, unless your claim is for more than US $10,000.
The arbitration will be governed by the Commercial Arbitration Rules and the Supplementary Procedures for Consumer Related Disputes (collectively, "AAA Rules") of the American Arbitration Association ("AAA"), as modified by these Terms & Conditions, and will be administered by the AAA. The AAA Rules and Forms are available online at www.adr.org, by calling the AAA at 1-800-778-7879, or by requesting them from us by writing to us at the Notice Address. The arbitrator is bound by the terms of these Terms & Conditions. All issues are for the arbitrator to decide, including, but not limited to, issues relating to the scope and enforceability of these Terms & Conditions, including, but not limited to, this arbitration agreement.
Unless Pure Wellness Medical and you agree otherwise, any arbitration hearings will take place in New Jersey. Except as expressly set forth herein, the payment of all filing, administration, and arbitrator fees will be governed by the AAA Rules. Each party shall pay for its own costs and attorneys' fees, if any. However, if any party prevails on a statutory claim that affords the prevailing party attorneys' fees, or if there is a written agreement providing for payment or recovery attorneys' fees, the arbitrator may award reasonable fees to the prevailing party, under the standards for fee shifting provided by law.
YOU AND PURE WELLNESS MEDICAL AGREE THAT EACH MAY BRING CLAIMS AGAINST THE OTHER ONLY IN YOUR OR ITS INDIVIDUAL CAPACITY, AND NOT AS A PLAINTIFF OR CLASS MEMBER IN ANY PURPORTED CLASS OR REPRESENTATIVE PROCEEDING. Further, unless both you and Pure Wellness Medical agree otherwise, the arbitrator may not consolidate more than one person's claims with your claims, and may not otherwise preside over any form of a representative or class proceeding. The arbitrator may award declaratory or injunctive relief only in favor of the individual party seeking relief and only to the extent necessary to provide relief warranted by that party's individual claim.
If the arbitration terms and conditions of this Section 21 are found to be unenforceable, then (i) the entirety of this arbitration provision shall be null and void, but the remaining provisions of these Terms & Conditions shall remain in full force and effect, and (ii) exclusive jurisdiction and venue for any claims will be in state or federal courts located in and for New Jersey.
22. Force Majeure
We will not be deemed to be in breach of these terms or liable for any breach of these terms or our privacy policy due to any event or occurrence beyond our reasonable control, including without limitation, acts of God, terrorism, war, invasion, failures of any public networks, electrical shortages, earthquakes or floods, civil disorder, strikes, fire, or other disaster.
23. Indemnification
You agree to defend, indemnify, and hold harmless Pure Wellness Medical, and any affiliates from and against any and all rights, demands, losses, liabilities, damages, claims, causes of action, actions, and suits (no matter whether at law or equity), fees, costs, and attorney's fees of any kind whatsoever arising directly or indirectly out of or in connection with: (i) your use or misuse of the Site, Products, Services or any information posted on the Site; (ii) your breach of the Terms & Conditions or Privacy Policy; (iii) the content or subject matter of any information you provide to Pure Wellness Medical, or any Provider or customer service agent; and/or (iv) any negligent or wrongful act or omission by you in your use or misuse of the Site, Products, Services, or any information on the Site, including without limitation, infringement of third party intellectual property rights, privacy rights, or negligent or wrongful conduct.
24. Application Support; Functionality
All questions and requests relating to Site support must be directed to Pure Wellness Medical. To submit a support request, please email us at info@purewellnessmedical.com or call us at (855) 679-7873. The Select Third Parties, are not responsible for providing support for the application portions of the Site and may not be contacted for support. Pure Wellness Medical will use commercially reasonable efforts to respond to questions and provide support during 9:00 a.m. ET through 5:00 p.m. ET. Please note that we may change or remove functionality and other features of the Site at any time, without notice.
25. Modified Devices and Operating Systems
Pure Wellness Medical will have no liability for errors, unreliable operation, or other issues resulting from use of the Site on or in connection with rooted or jail broken devices or use on any mobile device that is not in conformance with the manufacturer's original specifications, including, but not limited to, use of modified versions of the operating system (collectively, "Modified Devices"). Use of the Site on Modified Devices will be at your sole and exclusive risk and liability.
26. No Liability for Select Third Parties
Your wireless carrier, the manufacturer and retailer of your mobile device, the developer of the operating system for your mobile device, the operator of any application store, marketplace, or similar service through which you obtain the Site, and their respective affiliates, suppliers, and licensors (collectively, the "Select Third Parties") are not parties to these Terms & Conditions and they do not own and are not responsible for the Site. Pure Wellness Medical, and not any Select Third Parties, is responsible for addressing any claims raised by you or any third party regarding the Site or your use or possession thereof, including, but not limited to, claims related to product liability, legal, or regulatory requirements, and consumer protection or similar legislation. You are responsible for complying with all application store and other applicable Select Third Parties' terms and conditions.
YOU AGREE: (A) THE SELECT THIRD PARTIES DISCLAIM ALL WARRANTIES, EXPRESS AND IMPLIED, WITH RESPECT TO THE SITE, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OF NON-INFRINGEMENT, TITLE, MERCHANTABILITY, QUIET ENJOYMENT, QUALITY OF INFORMATION, AND FITNESS FOR A PARTICULAR PURPOSE; (B) IN NO EVENT WILL THE SELECT THIRD PARTIES BE LIABLE TO YOU OR ANY THIRD PARTY FOR ANY DIRECT, INDIRECT, PUNITIVE, EXEMPLARY, INCIDENTAL, SPECIAL, OR CONSEQUENTIAL DAMAGES (WHETHER IN CONTRACT, TORT (INCLUDING NEGLIGENCE), OR OTHERWISE) ARISING OUT OF THIS AGREEMENT OR THE SITE, EVEN IF THEY HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES OR LOSSES; AND (C) IN ANY EVENT, THE MAXIMUM LIABILITY OF ANY SELECT THIRD PARTY FOR ALL CLAIMS (WHETHER IN CONTRACT, TORT (INCLUDING NEGLIGENCE), OR OTHERWISE) OF EVERY KIND WILL IN NOT EXCEED FIVE DOLLARS ($5.00); AND (IV) YOU WAIVE ANY AND ALL CLAIMS, NOW KNOWN OR LATER DISCOVERED, THAT YOU MAY HAVE AGAINST THE SELECT THIRD PARTIES ARISING OUT OF THE SITE AND THESE TERMS & CONDITIONS. THE THIRD PARTIES ARE INTENDED THIRD PARTY BENEFICIARIES OF THESE TERMS & CONDITIONS, AND ARE CAPABLE OF DIRECTLY ENFORCING ITS TERMS. NOTHING CONTAINED IN THESE TERMS & CONDITIONS WILL BE CONSTRUED AS MODIFYING OR AMENDING ANY AGREEMENTS OR OTHER TERMS BETWEEN YOU AND THE SELECT THIRD PARTIES WITH REGARD TO THEIR SUBJECT MATTER.
In the event of any claim that the Site or your possession and use of the Site infringes a third party's intellectual property rights, the Select Third Parties are not responsible for the investigation, defense, settlement, or discharge of the infringement claim.
27. Revisions; General
Pure Wellness Medical reserves the right, in its sole discretion, to terminate your access to all or part of this Site, with or without cause, and with or without notice. Pure Wellness Medical reserves the right to modify these Terms & Conditions at any time, effective upon posting. Any use of this website after such changes will be deemed an acceptance of those changes. You agree to review the Terms & Conditions each time you access this website so that you may be aware of any changes to these Terms. In the event that any of the Terms & Conditions are held by a court or other tribunal of competent jurisdiction to be unenforceable, such provisions shall be limited or eliminated to the minimum extent necessary so that these Terms & Conditions shall otherwise remain in full force and effect. These Terms & Conditions constitute the entire agreement between Pure Wellness Medical and you pertaining to the subject matter hereof. In its sole discretion, Pure Wellness Medical may from time-to-time revise these Terms & Conditions by updating this posting. You should, therefore, periodically visit this page to review the current Terms & Conditions, so you are aware of any such revisions to which you are bound. Certain provisions of these Terms & Conditions may be superseded by expressly designated legal notices or terms located on particular pages within this Site.
Copyright/Trademark Information. Copyright ©2018 Pure Wellness Medical, Inc. All rights reserved. All trademarks, logos, and service marks ("Marks") displayed on the Site are our property or the property of other third parties. You are not permitted to use these Marks without our prior written consent or the consent of such third party which may own the Marks.
How to Contact Us:
Pure Wellness Medical, PC
Attn: Customer Support
199 Washington Street
Northvale, NJ 07647
Telephone: (855)679-7873
Email: info@purewellnessmedical.com
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CONSENT FORM TO PARTICIPATE IN A RESEARCH STUDY
INTRODUCTION
This consent may contain words that you do not understand. Please ask the investigator or the study staff to explain any words or information that you do not clearly understand.
You are being asked to participate in a research study. This research is being conducted in order to determine the benefits of Hormone Replacement Therapy (HRT) and how it impacts overall weight loss and improved health, enhancing the subject's quality of life. The study is titled "Hormone Replacement Therapy, Weight Loss, and Improved Health on the Quality of Life" ("Research Study"). When you are invited to participate in research, you have the right to be informed about the study procedures so that you can decide whether you want to consent to participation. This form may contain words that you do not know. Please ask the researcher to explain any words or information that you do not understand.
You have the right to know what you will be asked to do so that you can decide whether or not to be in the study. Your participation is voluntary. You do not have to be in the study if you do not want to. You may refuse to be in the study, and there will be no adverse effects. If you do not want to continue to be in the study, you may stop at any time without penalty or loss of benefits to which you are otherwise entitled.
This research is funded by solely by Pure Wellness Medical ("PWM" or the "Company").
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Principal Investigator / Researcher:
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Dr. David Suarez
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Organization:
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Pure Wellness Medical
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Sponsor:
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Pure Wellness Medical
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Proposal & Version:
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Hormone Replacement Therapy, Weight Loss, & Improved Health on the Quality of Life
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Accessibility:
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Affiliated Medical Providers and the entire staff of Pure Wellness Medical are sponsoring this research.
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WHY IS THIS STUDY BEING DONE?
The purpose of this research is to look at laboratory data, patient symptoms, improvement of possible disease states/medical conditions, and quality of life.
HOW MANY PEOPLE WILL BE IN THE STUDY?
This study will be an ongoing study with no end date. At any point in time the data will be used to evaluate specific criteria and use; laboratory data, patient symptoms, improvement of possible disease states/medical conditions, and quality of life. This study will take part at any Pure Wellness Medical Facility.
WHAT AM I BEING ASKED TO DO?
You will be asked to get a full laboratory evaluation of not more than eighty blood markers, symptom evaluation and quality of life evaluation through questionnaires.
HOW LONG WILL I BE IN THE STUDY?
This study will be ongoing, and you can stop participating at any time without penalty.
WHAT ARE THE BENEFITS OF BEING IN THE STUDY?
Your participation will benefit people interested in hormone replacement therapy in addition to people interested in; optimizing health, weight loss, chronic inflammation, hormone imbalance/deficiency, high blood pressure, insulin resistance, diabetes, arthritis, insomnia and fatigue.
WHAT ARE THE RISKS OF BEING IN THE STUDY?
I understand there is risk of mild diarrhea, upset stomach, nausea, a feeling of pain and a warm sensation at the site of the injection, a feeling, or a sense, of being swollen over the entire body, headache and joint pain.
If any of these side effects become severe or troublesome, I will contact my physician immediately.
I understand that although rare, Bioidentical and Synthetic Hormone Replacement Therapy can result in serious side effects. Although this is a relatively rare occurrence, anyone taking Hormone injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of Hormone injections, and such side effects should be reported to a physician to be evaluated for seriousness. Uncommon and dangerous side effects include, but are not limited to:
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Headache
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Tiredness
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Digestive system problems
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Menopausal symptoms (for females)
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Effects on your muscles and bones
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Weight gain
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Memory problems
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Mood swings and depression
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Water retention
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Problems getting an erection (for males)
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Hot flushes and sweating
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Indigestion or nausea
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Sleeplessness
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Before starting the Bioidentical and Synthetic Hormone Replacement Therapy, I will make sure to tell my Physician if I am pregnant, lactating or have any of the following conditions.
If I receive Testosterone (as a male), there is a possibility that I may become infertile. I was warned about this possibility and have decided to go through with the treatment plan regardless of the risks.
I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and non-prescription medications may result in side effects when they interact with Bioidentical and Synthetic Hormone Replacement Therapy.
Treatments: Will be determined by the provider.
WHAT OTHER OPTIONS ARE THERE?
All risks and benefits of treatment, non-treatment have been discussed in detail, all questions have been asked and answered to my satisfaction. I am prepared to continue with the treatment plan and I accept all possible risks and complications.
You also have the option of not participating in this study, and will not be penalized for your decision.
CONFIDENTIALITY
Information produced by this study will be stored in the investigator's file and identified by a code number only. The code key connecting your name to specific information about you will be kept in a separate, secure location. Information contained in your records may not be given to anyone unaffiliated with the study in a form that could identify you without your written consent, except as required by law.
In addition, if photographs, audiotapes or videotapes were taken during the study that could identify you, then you must give special written permission for their use. In that case, you will be given the opportunity to view or listen, as applicable, to the photographs, audiotapes or videotapes before you give your permission for their use if you so request.
WILL I BE COMPENSATED FOR PARTICIPATING IN THE STUDY?
You will receive no payment for taking part in this study.
WHAT ARE MY RIGHTS AS A PARTICIPANT?
Participation in this study is voluntary. You do not have to participate in this study.
You will also be informed of any new information discovered during the course of this study that might influence your health, welfare, or willingness to be in this study.
A Data Safety and Monitoring Board, an independent group of experts, will be reviewing the data from this research throughout the study. We will tell you about the new information from this or other studies that may affect your health, welfare, or willingness to continue participation in this study.
WHO DO I CONTACT IF I HAVE QUESTIONS, CONCERNS, OR COMPLAINTS?
Please contact Pure Wellness Medical, Dr. David Suarez, if you have questions about the research. Additionally, you may ask questions, voice concerns or complaints to the research team.
WHOM DO I CALL IF I HAVE QUESTIONS OR PROBLEMS?
If you have any questions regarding your rights as a participant in this research and/or concerns about the study, or if you feel under any pressure to enroll or to continue to participate in this study, you may contact the Pure Wellness Medical at 855-679-7873 or email us at info@purewellnessmedical.com
You may ask more questions about the study at any time. For questions about the study or a research-related injury, contact Pure Wellness Medical at 855-679-7873 or email us at info@purewellnessmedical.com
A copy of this Informed Consent Policy is available on our website at any time and will be provided to you upon request. It will also be provided to you prior to participating in the research.
SIGNATURES
By execution of our Client Agreement, which references and incorporates this Informed Consent Policy, you agree that you have read and understood this Informed Consent Policy, had an opportunity to asks any and all questions, and all questions have been answered to your full satisfaction. By execution of your signature, you agree that you want to be in the study, agree to its terms, and that you can remove yourself at any time.
Note by way of the certification below, Dr. Suarez certifies that he has read this Informed Consent Policy to the subject and, to the best of his ability, has ensured the subject understands the research. Dr. Suarez certifies that the subject was given the chance to ask questions and that the questions were answered truthfully and to the best of his ability. Dr. Suarez certifies the subject has not been coerced into giving consent, and that the subject's consent has been given freely and voluntarily.
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Signature
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______________
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Investigator / Researcher
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Dr. David Suarez
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By signing the Client Agreement and continuing to use the Pure Wellness Medical ("PWM") Services, you are agreeing to have any issue of medical malpractice and any other issues decided by neutral arbitration and you are giving up your right to a jury or court trial.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court and all class action cases against the physician, or the physicians partners, associates, association, corporation or partnership, and the employees, agents and estates, must be resolved by means of binding arbitration before a single arbitrator in accordance with the then existing Commercial Arbitration Rules of the American Arbitration Association, including the Optional Rules for Emergency Measures of Protection. The arbitrator shall be a practicing attorney or retired judge with at least 15 years total work experience as such. The arbitration shall be held in New Jersey or any other place agreed upon at the time by both parties. No demand for arbitration may be made after the date when the institution of legal or equitable proceedings based on such claim or dispute would be barred by the applicable statute of limitation. The arbitrator is not authorized to award punitive or other damages not measured by the prevailing party's actual damages.
A party may apply to the arbitrator seeking injunctive relief until an arbitration award is rendered or the dispute is otherwise resolved. A party also may, without waiving any other remedy, seek from it any court having jurisdiction any interim or provisional relief that is necessary to protect the rights or property of that party pending the arbitrator's appointment or decision on the merits of the dispute. If the arbitrator determines that a party has generally prevailed in the arbitration proceeding, then the arbitrator shall award to that party its reasonable out-of-pocket expenses related to the arbitration, including filing fees, arbitrator compensation, attorney's fees, and legal costs.
Pure Wellness Medical, PC
Attn: Legal Department
199 Washington Street
Northvale, NJ 07647
Telephone: (855)679-7873
Email: info@purewellnessmedical.com
After demand for arbitration has been made by serving written notice under this Agreement, the party demanding arbitration shall file a demand for arbitration with the American Arbitration Association (AAA) in New Jersey.
A neutral arbitrator shall be selected from the AAA panel and the arbitration shall be conducted pursuant to AAA policies and procedures. Except as provided herein, all rules governing the arbitration shall be the then applicable rules set forth by the AAA. The AAA's then applicable rules governing the arbitration may be obtained from the AAA's website, which currently is www.adr.org.
The arbitrator shall apply the substantive law (and the law of remedies, if applicable) of the state of New Jersey as applicable to the claim(s) asserted. The arbitrator shall have exclusive authority to resolve any dispute relating to the interpretation, applicability, enforceability or formation of this Agreement, including but not limited to any claim that all or any part of this Agreement is void or voidable.
Either party may file a motion for summary judgment with the arbitrator. The arbitrator is entitled to resolve some or all of the asserted claims through such a motion. The standards to be applied by the arbitrator in ruling on a motion for summary judgment shall be the applicable laws as specified in this Agreement.
Discovery shall be allowed and conducted pursuant to the then applicable arbitration rules of the AAA, provided that the parties shall be entitled to discovery sufficient to adequately arbitrate their claims and defenses. The arbitrator is authorized to rule on discovery motions brought under the applicable discovery rules.
THE CLIENT FURTHER ACKNOWLEDGES THAT THE CLIENT HAS BEEN GIVEN THE OPPORTUNITY TO DISCUSS THIS AGREEMENT WITH THE CLIENTS PRIVATE LEGAL COUNSEL AND THE CLIENT HAS UTILIZED THAT OPPORTUNITY TO THE EXTENT DESIRED.
Agreed By:
Pure Wellness Medical and the Entire Staff of Pure Wellness Medical
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HIPAA NOTICE OF PRIVACY PRACTICES & POLICY
THIS Health Insurance Portability & Accountability Act NOTICE ("HIPAA Notice") DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.
As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.
Treatment means providing, coordinating, or managing health care and related services by one or more health care providers.
Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and client service. An example would be an internal quality assessment review.
We may also create and distribute de-identified health information by removing all references to individually identifiable information.
We may use or disclose protected health information to carry out treatment, payment, or health care operations in the following circumstances:
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. This notice is effective as of January 1st, 2019, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. You may request a written copy of a revised Notice of Privacy Practices from this office.
CHANGES TO THE TERMS OF THIS NOTICE
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, and a copy will be provided to you.
FOR MORE INFORMATION
For more information, contact the Privacy Officer or visit the HHS website directly at:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
COMPLAINTS.
You have recourse if you feel that your privacy protections have been violated. You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.
Pure Wellness Medical
P: 855-679-7873
Email: info.purewellmed@gmail.com
For more information about HIPAA or to file a complaint:
U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
(202) 619-0257
Toll Free: 1-877-696-6775
www.hhs.gov/ocr/privacy/hipaa/complaints/
ACKNOWLEDGMENT
The Client understands and acknowledges that (a) the Client has a right to receive a separate copy of this HIPAA Notice, (b) that the Client has read, understood, analyzed, and considered the terms of this HIPAA Notice, and without any duress, undue influence or undue pressure from PWM or Dr. Suarez, has agreed to its terms, which is evidenced by execution of the Client Agreement. The continuing understanding and adherence to these terms is also evidenced by the Clients continued use of the services offered by PWM and Dr. David Suarez. The Client acknowledges and agrees that at the time of execution of the Client Agreement, the client has been made aware of, been given (if required) and been offered a full copy of this HIPAA Notice.
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Hormone Replacement Therapy Consent
Hormones are generated by your body's endocrine glands and work as messengers to trigger certain tissues or organs to respond in different ways. Hormones can provide benefits such as: aid in growth and development, support metabolic activity, stimulate sexual function, help with reproductive purposes, and to enhance your mood. The body is extremely sensitive to the amount of hormones in the bloodstream and a hormone imbalance can occur if there is too little or too much of the chemical. Sometimes an injection of a particular hormone may be necessary to support normal bodily function. Bioidentical and/or Synthetic Hormone Replacement Therapy ("HRT") is off label use of hormones and for symptom relief and taken at your own risk. HRT has many beneficial effects and is taken in the attempt to improve quality of life.
HRT treatments go directly into the blood stream and may come in several forms such as Injections, Creams, Gels, Capsules, Tablets, Sublingual, Inhalation etc.
The common side effects of HRT include but are not limited to:
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mild diarrhea
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upset stomach
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nausea
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feeling of pain and a warm sensation at the site of the injection
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a feeling, or a sense, of being swollen over the entire body
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headache
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joint pain
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If any of these side effects become severe or troublesome, you are to notify PWM immediately, and it is strongly recommended that you contact your general physician immediately for an opinion or evaluation.
Although rare, anyone who is undergoing HRT could be on the receiving end of serious side effects. While this is a relatively rare occurrence, anyone taking Hormone injections should be aware of the possibilities and assess the risks. Uncommon side effects are much more serious than the common side effects of Hormone injections, and such side effects should be reported to a physician to be evaluated for seriousness. Uncommon and dangerous side effects include, but are not limited to:
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Headache
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Tiredness
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Digestive system problems
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Menopausal symptoms (for females)
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Effects on your muscles and bones
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Weight gain
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Memory problems
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Mood swings and depression
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Water retention
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Problems getting an erection (for males)
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Hot flushes and sweating
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Indigestion or nausea
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Sleeplessness
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Before starting HRT, it is strongly recommended that you have this discussion with your general and primary care physician, especially if you have the following conditions:
Males undergoing HRT are advised of the possibility that you may become infertile, may get testicular atrophy, may get erythrocytosis from an increase in red blood cell progenitor cell production, not an increase erythropoietin. Some observational studies state that you may have an increased risk for myocardial infarction (heart attack), blood clots and strokes but no randomized control studies show this.
Testosterone hormone or Testosterone increasing supplements are not given to treat hypogonadism or any other disease state. It is prescribed as an off-label use to improve symptoms and quality of life.
Thyroid hormone or Thyroid increasing supplements are not given to treat hypothyroidism or any other disease state. Thyroid hormone or Thyroid increasing supplements are prescribed as an off-label use to improve symptoms and quality of life.
Estradiol in men and women has been shown in multiple grade a studies to reduce morbidity and mortality by; decreasing LDL and increasing HDL cholesterol, decrease risk and events of heart attacks, strokes, blood clots, and cancer. There are observational studies that extrapolate Estrogen (not Estradiol) may increase breast cancer, cervical cancer, stroke, pulmonary embolism, and blood clots.
All risks and benefits of treatment, non-treatment have been discussed in detail, all questions have been asked and answered to my satisfaction. The Client is fully informed, advised and is prepared to continue with the treatment plan.
The Client understands that certain herbal products, vitamins, minerals, nutritional supplements, prescription, and non-prescription medications may result in side effects when they interact with HRT.
We offer a range of therapeutic medications and hormones that are FDA approved but that may have other uses other than their FDA indications. All possible side effects, risks, and benefits of treatment and non-treatment are discussed with the Client. The Client has decided that they would like the treatment due to the reasoning that the benefit outweighs the risk.
Treatments: Will be determined by the provider.
The Client understands and agree that all services rendered to me are charged directly to the Client and that the Client is personally responsible for payment. the Client further agrees that in the event of non-payment, the Client will bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required.
By execution of our Client Agreement, which references and incorporates this HRT Consent Policy, you agree that you have read and understood this HRT Consent Policy, had an opportunity to asks any and all questions, and all questions have been answered to your full satisfaction. By execution of your signature on the Client Agreement, and by continuing to participate in any PWM programs, receiving services, you hereby agree and give consent to perform all HRT treatments with the above understood and you are fully informed as to all risks to your satisfaction. The Client hereby gives full consent to undergo HRT, and hereby releases the doctor, Dr. David Suarez, PWM, the medical & non-medical staff, and the facility from liability associated with this procedure.
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Electronic Communication Delivery Policy (E-SIGN Disclosure & Consent)
Purpose and Scope of Policy
Pure Wellness Medical ("PWM" or "Company") has adopted this electronic signature policy ("E-Sign Policy") to conduct business in an efficient manner by permitting the use and acceptance of electronic signatures ("e-signatures") as an acceptable alternative to manual (i.e., written) signatures (to the fullest extent permissible under applicable law) when entering into written agreements with U.S. based counterparties. Pursuant to the ESIGN Act of 2000, an "e-signature" is defined as "an electronic sound, symbol, process attached to or logically associated with a contract or other record and executed or adopted by a person with the intent to sign the record and be legally bound." In other words, it is a paperless (i.e., digital) method of executing an agreement or other document with the intent to bind the Company.
This E-Sign Policy supersedes and replaces any prior rules, standards, or policies that Company may have had established prior to the Effective Date with respect to its use and acceptable of e-signatures.
This E-Sign Policy applies exclusively to domestic transactions. We do not extend the right to use or accept e-signatures in connection with any agreement (1) to be entered into with any non-U.S. person or entity; and/or (2) where the transaction(s) covered thereby will not take place exclusively in the U.S., unless prior written approval is first obtained. Approvals must be obtained from PWM directly and in writing for any changes to the terms herein.
This E-Sign Policy applies to every individual executing an agreement or other documentation on our behalf at any time. It sets forth the requirements and guidelines to be followed in connection with our use and acceptable of e-signatures. Please note that while we have established this E-Sign Policy in connection with our acceptance of e-signatures, Company does not, at any time, require any employee to make use of this method in lieu of obtaining or providing handwritten signatures on any of our agreements or other documentation.
Pre-Requisites to the Use of E-Signatures
The following requirements must be met prior to any use or acceptable of an e-signature on Company's behalf:
If any of the aforementioned requirements are not met, you may not use or accept e-signatures on the applicable agreement unless prior written approval is obtained from [contact information/department/person] at [contact phone/email].
E-Mail and Other Electronic Correspondence
Extreme care must be taken when sending e-mails that could reasonably be considered an acceptance of any term, condition, covenant, agreement, representation, warranty, commitment, or arrangement of any kind, as this could unintentionally bind Company to an unwanted, enforceable contract. When in doubt, include a statement such as: "The statements set forth in this email in no way create an enforceable agreement upon either the sender or the recipient hereof." For additional guidance, please contact PWM directly.
Signature Authentication
While we do not dictate a particular method that must be used for obtaining or providing an e-signature, the party is recommended to take whatever steps are necessary to (1) obtain mutual consent, preferably in writing, to conduct business electronically (most leading e-signature software prompt users to confirm their consent before they sign); (2) authenticate all e-signatures; (3) verify that the agreement executed is identical to the document which the signatory intended to sign and therefore be bound by; and (4) protect the confidentiality of all applicable proprietary information throughout the entire process.
Related Policies
Please be reminded that this Policy should be adhered to in conjunction with all other applicable Company policies
Electronic delivery of communications
The Client agrees and consents to receive electronically all communications, agreements, documents, notices and disclosures (collectively, "Communications") that we provide in connection with your PWM Client Account ("Client Account") and your use of our services.
Communications may include, but are not limited to:
We will provide these Communications to you by posting them on the PayPal website and/or by emailing them to you at the primary email address listed in your PayPal profile.
Hardware and Software Requirements.
In order to access and retain electronic Communications, you will need the following computer hardware and software:
We will notify you if there are any material changes to the hardware or software needed to receive electronic Communications from PWM. By giving your consent you are confirming that you have access to the necessary equipment and are able to receive, open, and print or download a copy of any Communications for your records. You may print or save a copy of these Communications for your records as they may not be accessible online at a later date.
How to withdraw your consent
You may withdraw your consent to receive Communications electronically by writing to us at
Pure Wellness Medical, PC
Attn: Electronic Communications Delivery Policy
199 Washington Street
Northvale, NJ 07647
Telephone: (855) 679-7873
Email: info@purewellnessmedical.com
If you fail to provide or if you withdraw your consent to receive Communications electronically, PWM reserves the right to either deny your application for an Account, restrict or deactivate your Account, close your Account and any sub-account (such as a Student Account), or charge you additional fees for paper copies.
Requesting paper copies of electronic Communications
If, after you consent to receive Communications electronically, you would like a paper copy of a Communication, you may request a copy within 180 days of the date we provided the Communication to you by contacting us as described above. We will send your paper copy to you by U.S. mail, to the address identified in your Client Account. You may be charged a paper fee, should the request exceed $10.
Spam
Please note that if you use a spam filter that blocks or re-routes emails from senders not listed in your email address book, you must add all addresses from PWM to your email address book so that you will be able to receive the Communications PWM sends to you.
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Note that this MEMBER AGREEMENT ADDEDUM is part of every single Membership Agreement executed by each and every single Client who has retained services from Pure Wellness Medical, PLLC, Inc. d/b/a Pure Wellness Medical, PLLC ("PWM" or "Company"). At all points in this, the terms as published in this Member Agreement Addendum control, and unless expressly agreed to in writing between the parties prior to the start of the relationship, must always be adhered to. The terms of this Member Agreement Addendum, along with any and all other terms as published on this webpage, are incorporated into the underlying Member Agreement, and when you see the term "Agreement" being used, it shall include all the published documents on the webpage.
Herein, the "Member" or "Client," for purposes of the Agreement, when singular, either may be referred to as the Party, or when plural, the Parties.
Member agrees to give PWM their complete and accurate insurance information for primary and secondary insurance benefits. Member understands that a failure to do so may result in a delay in payment or denial of claim. In the event of any balance after Insurance, the Member agrees to pay accordingly. The Member understands that the Insurance Carrier may not agree to the usual, customary or reasonable charges for my local area, understands they may not cover all services or might deny payment for services that have been approved of in advance, and agrees to pay the balance remaining on the Member account after insurance has been processed.
The Member agrees that if the Insurance Carrier requires the Member to provide a referral and if the referral is not in place before the Members appointment, the Member will pay in advance an estimate of charges for my office visit or reschedule my appointment.
In the event that some services are not covered, and are considered complimentary/alternative medicine, not covered by insurance, the Member will accept full financial responsibility and agree to pay the balance in full. Member is obligated to pay any balance remaining on the Member's account for any reason upon receipt of a statement.
The Member understands that there is a charge if there is a missed appointment, or cancelled appointment, without a 24-notice period. If the Member fails to provide at least a full 24-prior notice of a missed appointment or cancellation, the Member will be charged $100 for the missed office visit.
PWM does not have a contract with the Member's Insurance Carrier and is generally considered "out of network." For this reason, the Insurance Carrier either may not provide the Member with any available benefits, or if they do, the payment may not go to PWM, but rather, to the Member.
If the Member receives the check from the Insurance Carrier, the Member is required to bring the check and all paperwork to the PWM office and endorse the check to PWM. In the event that PWM does not receive payment in a timely manner, PWM will be forced to bill the Member the full amount, and in some cases, refer the Member to collections, who will charge also for any applicable penalties such as debt collection and attorneys fees.
This also applies to any fees let unpaid by the guarantor on any account. Members are considered guarantors of the fees applied to their account, and are responsible for this balance. Member is responsible for any and all deductibles and co-payments, and in the event the Member fails to pay such fees due at the time of service, the Member may be subject to a rescheduling of their appointment.
Member understands and agrees that if the Member account becomes delinquent, the Account may be forwarded to an outside collection agency without notice. If this happens, the Member will be responsible for all costs of collection, including but not limited to interest, rebilling fees, court costs, attorney fees, and collection agency costs.
If the reason for the Members appointment is related to a work injury or auto accident, the Member agrees to give PWM the case number or policy number, the workman's compensation or insurance carrier's name, address or other contact information at the time of the Members appointment so that PWM can bill workman's compensation or the auto insurance carrier for my visit. If the Member fails to do so, they will agree to pay for all charges for the Member's visit.
MEMBER HEREBY ACKNOWLEDGE THAT MEMBER HAS FULLY READ AND UNDERSTANDS EACH OF THE ABOVE PROVISIONS AND THAT MEMBER UNDERSTANDS AND ACKNOWLEDGES MEMBER IS GIVING UP SIGNIFICANT LEGAL RIGHTS ON MINE, INCLUDING THE RIGHT TO SUE PWM. MEMBER ACKNOWLEDGES THAT PRIOR TO SIGNING THIS AGREEMENT I HAD THE OPPORTUNITY TO CONSULT WITH AN ATTORNEY TO REVIEW THIS AGREEMENT. MEMBER IS AT LEAST EIGHTEEN (18) YEARS OF AGE AND FULLY COMPETENT, AND I EXECUTE THIS AGREEMENT VOLUNTARILY AND FOR ADEQUATE CONSIDERATION INTENDING TO BE FULLY BOUND.
