JMB Medical Group
TERMS AND CONDITIONS OF SERVICES & PAYMENT
By signing below, you are agreeing to the following Terms and Conditions of our engagement. You must return a signed copy of this document to JMB Medical Group prior to receiving services. The services recipient is referred to herein as “client” or “you”. These terms to which you agree are referred to as “Terms and Conditions” or “Agreement”.
Insurance Not Accepted; Client’s Responsibility for Payment.
CLIENT UNDERSTANDS AND ACKNOWLEDGES THAT JMB Medical Group AND ITS PERSONNEL ARE NOT PAID OR REIMBURSED FOR THE SERVICES AND HANGOVER MANAGEMENT PROGRAM OR SUPPLEMENTS, VITAMINS OR PHARMACEUTICALS OFFERED BY JMB Medical Group BY MANAGED CARE PLANS, MEDICARE, MEDICAID, OR OTHER THIRD PARTY PAYOR PROGRAMS INCLUDING YOUR HEALTH INSURANCE CARRIER, AND DO NOT ACCEPT INSURANCE FOR SUCH SERVICES.
Clients will be BILLED DIRECTLY and shall be personally responsible for payment, regardless of whether clients are reimbursed by their insurance company, managed care plan or other third party payer.
***SPECIAL NOTICE AND ACKNOWLEDGEMENTS***
JMB Medical Group does NOT diagnose or treat any illness, disease or health condition.
Upon entering into these Terms and Conditions, you expressly represent and warrant that you are not engaging JMB Medical Group or its personnel with the expectation that it or they will diagnose or otherwise provide treatment for any illness, disease or condition of any nature. JMB Medical Group personnel will not screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions. JMB Medical Group is relying upon the foregoing representations and warranties upon your entering into these Terms and Conditions and upon JMB Medical Group’s acceptance of you for the provision of services.
This Agreement shall be governed by the laws of the State of New York, without regard to its conflicts of law rules. The parties hereby agree that any and all proceedings related to or arising out of this Agreement shall be maintained in the courts in New York County, which court shall have exclusive jurisdiction for such purpose, and by execution and delivery of this Agreement, each party waives to the fullest extent permitted by law any objection which it may now or hereafter have to the venue of such courts, and further waives any claim that any such action or proceeding brought in any such court has been brought in an inconvenient forum. The parties hereby acknowledge personal jurisdiction for the foregoing purpose. No delay or failure to exercise any remedy or right occurring upon any default shall be construed as a waiver of such remedy or right, or an acquiescence in such default, nor shall it affect any subsequent default of the same or a different nature. The provisions of this Agreement shall be severable, and if any provisions shall be prohibited by law, or invalid, or unenforceable in whole or in part for any reason, the remaining provisions shall remain in full force and effect. No party hereto shall be considered to be the drafter of this Agreement or any paragraph or term hereof and no presumption shall apply to any party as the “drafter.”
AGREED TO AND ACCEPTED:
Service Recipient Name: _________________________
Primary Phone: _____________________________________