Patient Services Agreement

My Elektra, Inc. (“Elektra Health”), through its partnerships with professional services corporations, including Electra Health Medical Mass PC, Electra Health Medical, P.C., Elektra Women’s Health Medical Inc., and Electra Women’s Health Medical NJ, PC (d/b/a Elektra Health Medical Services), is honored to provide you with personalized support and virtual care. Elektra Health provides management and administrative services to Elektra Health Medical Services; Elektra Health Medical Services is solely responsible for the delivery of medical and other licensed professional services (collectively, Elektra Health and Elektra Health Medical Services are referred to as “us”, “we”, “our”, or “them”).

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Although this document is long, it is very important that you understand it. When you sign this document, it will represent an agreement between us. Federal and state law requires that we provide to you certain information set forth in this document. A full copy of this Patient Service Agreement and Consent Form will be furnished for your records upon request. If you have any questions, please ask your provider or our office.

Scheduling Services. All services can be scheduled by visiting our website or logging into the Elektra Health secure patient portal or electronic medical record (“patient portal”).

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Payment. In addition to the foregoing authorization for assignment of benefits, by agreeing to use the Services, you acknowledge and agree that, to the extent the Services you use are NOT a “Covered Service” (as defined by your Health Plan)(“Non-Covered Services”) (i) you are explicitly choosing to obtain products and services on a cash basis outside of any federal or state healthcare program and you have sole financial responsibility for all Non-Covered Services provided to you, and (2) neither you nor Elektra Health nor the Practice will submit a claim for reimbursement to any federal or state healthcare program for the costs of such services and products provided to you through the Non-Covered Services.

Subject to any ability to refund as outlined herein, you agree that you will be charged for the Non-Covered Services, by providing a credit card or other payment method accepted by Elektra Health (“Payment Method”), and you are expressly agreeing that Elektra Health is authorized to charge to the Payment Method any fees for Non-Covered Services, together with any applicable taxes.

You agree that authorizations to charge your Payment Method remain in effect until you cancel it in writing by notification to Elektra Health at [email protected], and you agree to notify Elektra Health of any changes to your Payment Method. You certify that you are an authorized user of the Payment Method and will not dispute charges for the Non-Covered Services. You acknowledge that the origination of ACH transactions to your account must comply with applicable provisions of U.S. law. In the case of an ACH transaction rejected for insufficient funds, Elektra Health may at its discretion attempt to process the charge again at any time within 30 days.

Your payment for Telehealth Services and any other service you receive from Elektra Health Medical Services shall be made prior to or at the time of service, except for the portion of the payment that may be covered by your insurance plan. If you will be using insurance to cover some or all of the cost of your appointment, you should contact us ahead of your appointment to ensure that your insurance is accepted and provide a photo of your insurance card prior to the appointment via our patient intake or patient portal. You should be prepared to pay any co-payments prior to or at the time of the appointment. If we are out-of-network for your insurance, we may submit an out-of-network claim on your behalf and bill you only for the copayment, coinsurance, or amount not covered. We accept payment in the form of a credit card, which you expressly authorize for us to charge for the Telehealth Services and any other service you elect to receive from Elektra Health Medical Services that is not covered by your insurance.

Cancellation Policy. For any appointment that is scheduled in advance, excluding on-demand chat-based care interactions, you understand that your appointment must be canceled no less than twenty four [24] hours in advance or you will be responsible for a $50 fee, unless your insurance prohibits us from billing you for missed visits.

Consent for Assignment of Insurance Benefits. You authorize the payment of insurance benefits directly to us, and you assign and transfer to us all right, title, and interest in the right to receive all benefits payable for the health care rendered that are provided for in any and all insurance policies and/or plans that will be applied to the amount charged for services rendered by your Elektra Health Medical Services provider(s). If Elektra bills your insurance company, other third-party payer, or a self-insured employer, you may be liable for any amounts not paid, whether the insurance company, third-party payer, or self-insured employer makes partial payment or declines to pay to Elektra.

You further authorize and irrevocably assign to Elektra Health the following rights:

1. To communicate with your Health Plan, to request any adjustment to your Health Plan’s reimbursement of the Services provided, and to file any and all necessary claims, demands or appeals with your Health Plan arising from a denied, underpaid or misclassified claim;
2. To demand and receive the production of, or access to, any documents and information, including, without limitation, any copies of Health Plan documents, coverage policies, guidelines and any other materials affecting the coverage and reimbursement of any Services provided to you, from any entity or person to the fullest extent of your rights to do so under applicable law;
3. To bring legal action, if needed, in any forum against your Health Plan under applicable laws, including, without limitation, the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) and/or the Federal Employee Health Benefit Act, as amended;
4. To recover benefits under the terms of your Health Plan, to enforce your rights under the terms of your Health Plan, or to clarify your rights to future benefits under the terms of your Health Plan;
5. To enjoin any act or practice which violates any provision of ERISA or the terms of your Health Plan, or to obtain other appropriate equitable relief to redress such violations or to enforce any provisions of ERISA or the terms of your Health Plan; and
6. To recover the costs of pursuing such action, including, reasonable attorney fees, as permitted.
7. The foregoing designation and assignment of benefits and rights are without limitation and without reservation of any part or aspect thereof.

Telehealth. You agree to receive telehealth services (the “Telehealth Services”). Telehealth involves the use of audio, video, or other electronic communications to interact with you, consult with your health care provider or Elektra Guide, and/or review your medical information for the purpose of diagnosis, therapy, follow-up, and/or education; telehealth may be provided as synchronous (in real time) or asynchronous (not in real time, such as by sending a chat or a photo and later receiving a response). During your telehealth consultation with Elektra Health Medical Services providers, details of your medical history and personal health information may be disclosed and/or discussed with other health professionals through the use of interactive video, audio, and telecommunications technology. The benefits of telehealth include having access to specialists and additional medical information and education without having to travel outside of your home or local health care community. A potential risk of telehealth is that because of your specific medical condition or due to technical problems, a face-to-face consultation may still be necessary after the telehealth appointment. Additionally, in rare circumstances, security protocols could fail, causing a breach of patient privacy. The alternative to receiving Telehealth Services is a face-to-face visit with an independent provider other than Elektra. You understand the risks, benefits, and alternatives of receiving Telehealth Services. You may ask your provider any questions you may have regarding Telehealth Services. You may be requested to sign additional consents or provide additional information before receiving Telehealth Services if you reside in a state where additional documentation or additional information is required prior to receiving Telehealth Services.

Telehealth Services should not be used for a medical or mental health emergency; in a medical or mental health emergency you should dial 911, or if you are feeling suicidal, you should call or chat with the 988 Suicide & Crisis Lifeline.

Integrated Approach to Care in Regards to Data Sharing. Elektra Health Medical Services believes that the best care is provided when all members of your healthcare team work together in an integrated system of care. Accordingly, and in furtherance of this model, all professionals involved in your care, including primary care providers and Elektra Guides, may share information regarding your care and treatment in order to provide you with the best care possible for you, except when sharing this information is expressly prohibited by law. In addition, we sometimes work with third-parties who provide services on our behalf, such as help with coordinating your care. These third-parties may be considered business associates of ours and we will share your information with them as described in our Notice of Privacy Practices.

Elektra Health Online Questionnaire. You agree to: (i) fully, accurately and truthfully complete your Elektra Health Online Questionnaire or Intake Form; and (ii) prohibit anyone else from using your Elektra Health account employing information from your Elektra Health Online Questionnaire. You agree to provide accurate, current and complete information about yourself for your Elektra Health Online Questionnaire, and to periodically review and to update such information as needed to keep it accurate, current and complete. You agree to immediately notify Elektra Health of any actual or suspected unauthorized use of your Elektra Health account, profile or credentials or other security concerns of which you become aware.

Relationship with Practitioner. If you utilize telehealth services, you agree that you are entering into an agreement with Electra Health Medical, P.C., a New York professional service corporation, Electra Health Medical Mass, P.C., a Massachusetts professional service corporation, Elektra Women’s Health Medical, Inc., a Pennsylvania professional corporation, and/or Electra Women’s Health Medical NJ, PC, a New Jersey professional service corporation (collectively, the “Practice”) which shall be a provider of professional medical services to you, which means, among other things, you are entering into a practitioner – patient relationship with the physician or licensed practitioner associated with the Practice (collectively, the “Practitioners”) that personally performs the Services. You understand and agree that Elektra Health is the provider of certain administrative services to the Practice and provides access to a technology platform in order to facilitate the Services between you and the Practice and the Practitioners. You acknowledge that Elektra Health does not provide professional medical services itself and the Elektra Health website is for informational purposes only. Elektra Health does not provide medical advice, diagnosis, or treatment.‍‍

Confidentiality and Compliance. We will take appropriate precautions to keep your health information confidential. You are also protected under the provisions of the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and any other applicable federal and state laws related to the protection of patient information and how we will use and disclose your protected health information. Our Notice of Privacy Practices (“NPP”) discusses how we will use and disclose your protected health information; you have received a copy of our NPP, as it is available here. The most up-to-date NPP is posted on our website. We will not disclose your health information without your consent except as set forth in the NPP.

As set forth in the NPP, there are some situations in which we are legally obligated to take action and disclose your health information to protect yourself or others from harm, For example, if we become aware of child, elderly or other types of abuse or if a patient is threatening serious bodily harm to another, we may be required in certain states to disclose health information to state authorities or others.

Privacy Policy. You agree to Elektra Health’s Privacy Policy, the terms of which are incorporated herein by reference.

Medical Records. You agree to the entry of your medical records into Elektra Health’s and the Practice’s computer database and understand that reasonable measures have been taken to safeguard your medical information, in accordance with federal HIPAA standards, as amended to date, but no computer or phone system is totally secure. Elektra Health recognizes your privacy and, in accordance with Elektra Health’s Privacy Policy, will not release information to anyone without your written authorization or as required or permitted by law.

Consent to Call, Email, Text, and Patient Portal Messaging. You expressly consent to allow our agents and us to communicate with you by telephone call, email, text message, messaging via the patient portal, messaging via the membership platform, and/or other forms of unencrypted electronic messaging (“Electronic Messages”) using any telephone numbers or email addresses that you provide us or that we obtain lawfully, such as through caller ID. You expressly agree to receive prerecorded or automated Electronic Messages from us. You agree to receive these Electronic Messages from us even if your phone number is listed on the National Do Not Call Registry. You agree that you are the current owner of any telephone number you provide us. Wireless or data charges from your carrier may apply, and we are not responsible for these charges. 

• You understand that we do not require that you give your consent to receive automated Electronic Messages in order to receive services from us.
• You understand that Electronic Messages sent by us may include, without limitation, appointment reminders, changes in previously scheduled appointments, actions to take in advance of appointments, follow-ups from appointments, information regarding insurance and billing, marketing material, or advice or education. 
• You understand the risks associated with communicating through Electronic Messages, including, without limitation, that Electronic Messages can easily be mis-addressed to or forwarded to unintended recipients, that Electronic Messages can be stored, that backup copies of Electronic Messages may exist even after the Electronic Messages are deleted, that Electronic Messages may not be secure and thus may be used or forwarded without your permission or knowledge, that Electronic Messages may be inspected by your telephone carrier, and that Electronic Messages may be used as evidence in court. You understand that we are not liable for any breaches of confidentiality caused by you or a third party. 
• You agree that in a medical emergency, you should not use Electronic Messages. Instead, you should call 911.
• You understand that Electronic Messages may be filed in your medical record. 
• You may opt out of automated Electronic Messages, including in-app messages or notifications, SMS, and/or email, at any time. Your notification options and preferences are available in the Elektra Health patient portal. You may also send your request via secure message to the Elektra Health team or via email to [email protected]. You acknowledge and agree to receive a final message confirming your choice to opt out. Unless you revoke your consent to communicate with us via Electronic Messages, your consent will last through the end of your relationship with us. 
• You acknowledge that telephone calls to or from us may be monitored and recorded. You agree to this monitoring and recording. 
• You understand that if you send us an email, the email will not necessarily be read or responded to by a Practitioner.
• In exchange for the services provided by us, you release Elektra Health and Elektra Health Medical Services from all claims, causes of action, lawsuits, damages, losses, liabilities, or other harms relating to any Electronic Messages you exchange with them. You release Elektra Health and Elektra Health Medical Services from all claims, causes of action, or lawsuits based on any alleged violations of any laws, including the Telephone Consumer Protection Act, the Truth in Caller ID Act, the CAN-SPAM Act, the Fair Debt Collection Practices Act, the Fair Credit Reporting Act, HIPAA, any similar state and local acts or statutes, and any federal or state tort or consumer protection laws.

Acknowledgments.

You have read and understand the information provided above and understand and agree to the terms in this agreement, including the services, payment methods, and cancellation policy. Any questions you had have been answered. You consent to receiving telehealth services, as described above in Section 2. If you are receiving services in Connecticut, please see section 10a for additional disclosures regarding telehealth services. If you are receiving services in New Jersey, please see section 10b for additional disclosures regarding telehealth services.

You also understand that, under HIPAA, you have certain rights to privacy regarding your health information. You have received, read, and understand Elektra Health Medical Services’ NPP containing a complete description of the uses and disclosures of your health information. You understand that Elektra Health Medical Services has the right to change its NPP from time to time and that you may contact Elektra Health Medical Services at any time to obtain a current copy of the NPP.

1. Receiving Telehealth Services in Connecticut. If you are receiving telehealth services in Connecticut, at the time of your first consultation with an Elektra provider you will be informed about telehealth treatment methods, as well as their limitations. You will then be asked by the Elektra provider whether you consent to the provision of telehealth services, and, if so, asked whether you consent to Elektra sharing records regarding the telehealth services you receive with your primary care provider.
2. Receiving Telehealth Services in New Jersey. If you are receiving telehealth services in New Jersey, your provider’s name, contact information, and license, title, and any specialty and board certifications will be provided to you prior to your telehealth visit. You will also be provided information on who to contact after your visit.

• Your visit may occur with a professional who is not a physician – such as a physician assistant, nurse practitioner, or certified nurse midwife; if you only want to have a visit with a physician, please contact 646-760-6669 or email [email protected]. 
• If you experience an adverse reaction to your treatment, you may receive follow-up care by contacting 646-760-6669. 
• If you cannot reach your provider prior to, during your appointment time or after your appointment due to technological or equipment difficulties, please contact 646-760-6669 or email [email protected].
• You authorize Elektra to disclose medical records related to your telehealth encounter to your primary care provider or another provider that you identify upon your written request.

Date last modified: December 11, 2025