Program Membership Details

Womenkind Clinical Program

Program Description: The WomenKind Clinical Program is a physician-directed women’s health program focused on the evaluation, treatment, and optimization of menopause and midlife health concerns. The program includes ongoing access to the WomenKind clinical team through secure messaging, physician follow-up visits as determined by the Provider based upon clinical need and treatment goals, treatment monitoring and adjustment, andcare coordination services designed to support each patient’s individualized treatment plan. Non-emergency communications will generally be addressed within one (1) business day.WomenKind works collaboratively with each patient to evaluate and manage their treatment plan, including prescription therapies and other interventions that may be medically appropriate, with the goal of optimizing health outcomes and achieving the patient’s individual health objectives.
Membership Terms: Enrollment in the WomenKind Clinical Program requires a minimum initial commitment of three (3) months. Membership fees begin upon enrollment and are billed monthly. Following completion of the initial three (3) month commitment period, membership shall automatically continue on a month-to-month basis unless cancelled in accordance with the terms of the Membership Agreement.
Membership Fee: $350 per month.
Program Eligibility: Eligibility for the WomenKind Clinical Program requires completion of a Comprehensive Foundational Consultation.
Program Exclusion: If deemed medically appropriate, Provider may order external diagnostic exams, laboratory testing, and prescription medications. Diagnostic exams, laboratory testing, and prescription medications are provided by ancillary third parties and are not included in the program membership fee. The membership fee includes the ordering of laboratory tests and interpretation of the results.

Comprehensive Foundational Consultation (Required Initial Consultation)

Service Description: The Comprehensive Foundational Consultation is an in-depth, ninety
(90) minute clinical consultation with Provider. The Comprehensive Foundational Consultation includes a thorough review of the patient’s medical history, presenting symptoms, prior treatments, and health objectives, as well as development of an individualized care plan. The Comprehensive Foundational Consultation is a prerequisite for enrollment in the WomenKind Clinical Program.

One-time Comprehensive Foundational Consultation Fee of $650.
Eligibility: Comprehensive Foundational Consultation requires concurrent enrollment in the WomenKind Clinical Program.

FINANCIAL ACKNOWLEDGEMENT AND PAYMENT PROCESSING AGREEMENT

This Financial Acknowledgement and Payment Processing Agreement (“Agreement”) is entered into between Urban MD, PLLC d.b.a. WomenKind (hereafter, the “Practice”) and the undersigned patient (“Patient”) for the purpose of facilitating automatic payments for participation in the Practice’s professional membership program (“Program”).

Authorization for Automatic Payments.
The Patient authorizes Practice to use Square AdvancedMD pay and/or other approved payment processing providers to securely process an automatically charge the Patient’s designated payment method for all fees, charges, balances, an other amounts due under this Agreement, including recurring membership fees, consultation fees and any applicable charges. Such authorization shall remain in effect until revoked by the Patient in accordance with this Agreement and after satisfaction of all outstanding financial obligations owed to Practice.
Payment Terms and Program Enrollment Program Enrollment:
The Patient acknowledges and agrees that enrollment in the Program requires a minimum initial financial commitment of three (3) months (“Initial Program Term”). For th Initial Program Ter WomenKind Clinical Program Enrollment: The Patient agrees to pay a one-time Comprehensiv Foundational Consultation Fee of $650 and a Program Membership Fee of $350 per month. The Comprehensive Foundational Consultation Fee and first monthly membership fee shall be charged upon enrollment. Thereafter, the monthly membership fee shall recur automatically on the same day of each subsequent month (each, a “Due Date”). The Patient acknowledges and agrees that participation in the Program requires a minimum three (3) month commitment and that the Patient remains financially responsible for all fees associated with the Initial Program Term
Automatic Renewal.
The Patient acknowledges and agrees that enrollment in the Program requires a minimum initial commitment of three (3) months. Membership fees shall be charged monthly beginning on the enrollment date and on each monthly anniversary thereafter. Following completion of the Initial Program Term, membership shall automatically continue on a month-to-month basis unless and until cancelled by the Patient in accordance with Section 5 of this Agreement. The Patient authorizes Practice to continue charging the payment method on file for all amounts due under this Agreement until cancellation becomes effective.
Modification and Termination.
– The Patient may cancel this Agreement by providing written notice to Practice. The Patient acknowledges and agrees that enrollment in the Program requires a minimum initial commitment of three (3) months. Any cancellation request received during the Initial Program Term shall not relieve the Patient of responsibility for payment of all amounts due for the Initial Program Term. Following completion of the Initial Program Term, cancellation shall become effective at the conclusion of the then-current monthly billing period, provided all outstanding balances have been paid in full.
– No portion of any membership fee, whether paid or payable for the current membership term or any prior membership term, will be refunded, credited, or prorated. The cancellation shall become effective after all outstanding amounts are paid.
– The Patient expressly agrees that they will not be permitted to terminate this Agreement after delivery of any products in an attempt to avoid payment of all amounts owed. The full amount owed under this Agreement remains due and payable according to the payment terms outlined.
– Cancellation requests must be sent via email to Practice at info@womenkindhealth.com.
– The Patient agrees to update payment information promptly in the event of changes. Changes in payment information can be communicated to Practice by email to info@womenkindhealth.com or by calling (435) 252-0057.
– Practice reserves the right to suspend Program services until payment is received.
Refunds and Disputes.
– Except as expressly set forth herein, all payments are non-refundable. Any billing dispute must be submitted in writing to Practice within fourteen (14) days of the applicable transaction date.
– Failure to timely notify Practice shall constitute a waiver of such dispute to the extent permitted by law.
Agreement Duration. This Agreement remains in effect until canceled pursuant to Section 5.
Acknowledgment and Consent – By signing below, the Patient acknowledges they have read and understood the terms of this Agreement and authorizes automatic payments as described.

Patient Information:
Name:
Address:
Phone Number:
Email:
Patient Signature:
Date:
Practice Information:
Practice Representative:
Date: