We regard the patient-provider relationship with the utmost reverence, and we thank you for entrusting us with your health care. Communication is at the center of our care, and this Agreement explains how we will work together.

This Agreement is made between Gold Star Urgent Care, doing business as ("Practice"), and You ("You" or "Patient"). Practice offers urgent care services in exchange for certain fees paid by You as described in this Agreement on the terms and conditions described below.

1. Services

As used in this Agreement, the term Services means urgent care services and certain amenities (collectively "Services"), which are offered by Practice.

• Volume of Services - The number of in-person and virtual visits you may receive is not limited by this Agreement.

• Availability - Practice will make every effort to address Your medical needs in a timely manner. You may visit the urgent care an unlimited number of times within our hours of operation: Monday through Friday from 9AM - 6PM.

• Included Services - Your membership includes all basic urgent care services, including well and sick care, and telehealth visits. Your provider will make an appropriate determination about the scope of urgent care services offered by Practice on a case-by-case basis. Your membership includes:

- Unlimited urgent care visits with Provider evaluations

- Flu and strep swabs

- Up to 2 injections

- Written prescriptions

- Additional charge for send out labs

- Specialty services such as IV Hydration services will be offered at a 25% off discount rate.

• Excluded Services - You may need the care of hospitalists, specialists, emergency rooms, laboratory testing, radiologic testing, pathology studies, surgery and specialist consultations, and dispensed medications, including but not limited to scope of this Agreement. We highly recommend that you maintain health insurance, which may or may not cover the costs of these services. Practice will endeavor to place orders for Excluded Services in a manner that is cost effective for you. This membership does not included services such as:

                - Surgeries

                - Narcotics or controlled substances

                - X-Rays

2. Consent to Treat

You acknowledge and hereby authorize Practice to use and/or disclose Your health information which specifically identifies You, or which can reasonably be used to identify You, to carry out Your treatment, payment, and healthcare operations. Treatment includes but is not limited to: the administration and performance of all treatments, the administration of any needed anesthetics, the administration and use of prescribed medication, the performance of such procedures as may be deemed necessary or advisable for treatment, including but not limited to diagnostic procedures, the taking and utilization of cultures, and of other medically accepted laboratory tests, all of which in the judgment of the attending provider or their assigned designees may be considered medically necessary or advisable.

3. Scheduling

• You are welcome to come as a walk-in Monday through Friday from 9AM - 6PM.

• You are also welcome to make an appointment, appointments can be made the day of or in advance via our website or by calling the office at (843)407-4451. The last appointment we take each day is at 5:00pm.

• Missed Appointments: We kindly request that you provide us with a minimum of 24 hours notice if you are unable to attend a scheduled appointment. Your advance notice helps us provide the best possible experience for all of our patients.

4. Fees

In exchange for Services, You agree to pay Practice a) the Monthly Fee and b) any additional Itemized Charges (collectively "Fees") such as send out labs. In order to remain financially viable, Practice must, and does, reserve the right to change its fees at any time with thirty (30) days' notice to you. You must continue with our plan for a minimum of six months before being allowed to cancel or pause your monthly healthcare plan.

a. Monthly Fee - Your Monthly Fee is based upon selected monthly subscription. This fee is for urgent care services provided by Practice in the month for which the fee was received. Your monthly fee is due no later than the 1st day of the month and is payable by automatic debit from your bank or credit card account. Your plan can also be purchased through the Practice website. Plans purchased through the website will be automatically billed on the same day each month that you signed up for your monthly plan.

b. Student Semester Plan - College students are eligible for a student semester health plan. This plan includes all services listed above but offered at a semester rate. Must present school ID or other form of proof of enrollment to redeem this plan.

• $150/semester

• $225 Fall + Spring

• $300 Fall + Spring + Summer

5. Term

This Agreement will commence on the date it is signed by the parties and shall have an initial term of one (1) month. Upon the expiration of the initial term this Agreement shall automatically renew for successive monthly terms upon the payment of the Monthly Fee, until the Agreement is terminated pursuant to the terms of Section 6. This Agreement must be for a minimum of six months before being allowed to terminate this agreement.

6. Termination

Both You and Practice shall have the absolute and unconditional right to terminate the Agreement, without cause.

• While we value Your membership, you are under no obligation to continue receiving Services and You may terminate this Agreement, in writing, at any time after six months of service.

• If you terminate your membership before the end of the month, your bill will be prorated based upon the number of days membership was provided to You, plus any additional Itemized Charges incurred. Once your membership is terminated, you will not be eligible for any medical services through Practice, including medication refills.

• Notwithstanding any other provisions of this Agreement, if your decision to terminate is based on grievance with Practice, you will give us an opportunity to make it right, prior to issuing Your written notice of termination or taking other action.

• If Practice elects to terminate this Agreement, Practice will provide You with thirty (30) days written notice, or any such other time necessary to transition Your care to another provider.

• Practice has a right to determine whom to accept as a patient, just as You have the right to choose Your provider. There are certain circumstances in which we may choose to terminate this Agreement. Such circumstances may include, but we are not limited to the following:

  i. You fail to pay fees and charges when they are due.

  ii. You have performed an act that constitutes fraud.

  iii. You fail to adhere to the recommended treatment plan.

  iv. You are disruptive, abusive, or present an emotional or physical danger to the staff or other patients of Practice.

  v. Practice discontinues operation

7.      Re-Enrollment.

If You choose to discontinue Your membership and You later wish to re-enroll, Practice reserves the right to decline re-enrollment or require You to pay a re-enrollment fee that is equivalent to three (3) times the then existing Monthly Fee applicable to your membership, excluding discounts.

8.      Privacy & Communications.

a. Limited Disclosure. Practice will not disclose your Protected Health Information ("PHI") for reasons unrelated to the delivery of Services, or the provision of other health care services on Your behalf.

b. Your Privacy Rights. Practice will adhere to its obligations regarding your privacy rights as identified in Practice's Patient Notice of Privacy Practices.

c. Methods of Communication. You acknowledge that Practice communications may include e-mail, facsimile, video chat, instant messaging, and cell phone, and such communications by their nature cannot be guaranteed to be secure or confidential. If You initiate a conversation in which You disclose PHI on any of these communication platforms, then You authorize Practice to communicate with You regarding all PHI in the same format.

9.      Miscellaneous

a. Amendment. No amendment or variation of the terms of this Agreement shall be valid unless in writing and signed by both Parties.

b. Anti-Referral Laws. Nothing in this Agreement, nor any other written or oral agreement, nor any consideration in connection with this Agreement, contemplates or requires or is intended to induce or influence the admission or referral of any patient to or the generation of any business between Practice and any other person or entity. This Agreement is not intended to influence any Provider’s professional judgment in choosing the appropriate care and treatment of patients.

c. Assignment. This Agreement, and any rights You may have under it, are not assignable or transferable by You.

d. Authorization for Agreement. The execution and performance of this Agreement by Practice and You have been duly authorized by all necessary laws, resolutions, and corporate or partnership action, and this Agreement constitutes the valid and enforceable obligations of the parties in accordance with its terms.

e. Entire Agreement. This Agreement constitutes the entire agreement between the Parties with respect to the subject matter hereof, and supersedes any and all other agreements, understandings, negotiations, or representations, oral or written, between them.

f. Governing Law. This Agreement shall be subject to and governed by the laws of South Carolina, without regard to any conflicts of law provisions therein contained. All disputes arising out of this Agreement shall be settled by binding arbitration. The provider of arbitration services shall be made solely at Practice's discretion and costs of arbitration shall be borne equally by the parties.

g. Non-Discrimination. Under no circumstances will Practice discriminate against You, or terminate this Agreement, on the basis of sex, race, color, religion, ancestry, national origin, disability, medical condition, genetic information, status, or any other protected status. However, Practice reserves the right to accept or decline patients based upon our capability to appropriately manage the primary care needs of our patients.

h. Notices. Any notices or payments required or permitted to be given under this Agreement shall be deemed given when in writing, by electronic transmission, hand delivered, or with proof of deposit in the United States mail. All notices shall be deemed delivered on the date of actual delivery, as evidenced by the return receipt or courier record, or by verified digital date stamp in the case of electronic transmission.

i. Severability. If any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of the Agreement shall not be affected, and the offending provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable.

If this Agreement is held to be invalid or unenforceable for any reason, and if Practice is therefore required to refund all or any portion of the Monthly Fees paid by You, You agree to pay Practice an amount equal to the fair market value of the Services actually rendered to You during the period of time for which the refunded fees were paid commensurate with prevailing rates in the Practice area.

j. Survival. Any provisions of this Agreement creating obligations extending beyond the term of this Agreement shall survive the expiration or termination of this Agreement, regardless of the reason for such termination.

After submitting this form, you will be automatically redirected to another webpage to complete your purchase of your monthly VIP Plan with Gold Star Urgent Care.