Established February 1, 2026

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I understand and consent to using telehealth, SMS and email communication at RX14 Health PLLC and partners. I authorize my credit card to be charged the day of the appointment and be kept on file. I understand no shows and late cancellations of less than 48 hours will be charged for the full visit.

 

EPRESCRIBING CONSENT

ePrescribing is defined as a medical providers ability to electronically send a prescription directly to a pharmacy. Benefits data are maintained for health insurance companies by organizations known as Pharmacy Benefits Managers (PBM). PBM’s are third party administrators of prescription drug programs whose primary responsibilities are processing and paying prescription drug claims. By checking the box below you are agreeing that RX14 Health can request and use your prescription medication history from other healthcare providers and/or third party Pharmacy Benefits Managers for treatment purposes.

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COACHING SERVICE AGREEMENT

Purpose of Services: Coaching services provided by RX14 Health are intended to support clients in identifying personal, professional, and behavioral patterns that may influence progress toward their goals. Coaching may address areas related to lifestyle, health behavior, mindset, career, or business; however, RX14 Health does not guarantee specific outcomes, including but not limited to increased clientele, income, business growth, or personal success. Nature of Coaching: Coaching is not counseling, psychotherapy, mental health treatment, or medical care. Coaching services are not intended to diagnose, treat, or cure any medical or mental health conditions. RX14 Health does not act as a mental health provider or medical professional in the delivery of coaching services. Clients must disclose whether they are currently receiving or have previously received psychological or psychiatric care. Clients are responsible for informing RX14 Health if significant mental health concerns arise during the coaching relationship so that appropriate referrals can be made. Client Responsibility: Clients remain fully responsible for their own choices, actions, and results during and after coaching services. Participation is voluntary and undertaken at the client’s own discretion and risk. Liability Release: By engaging in coaching services, the client releases and discharges RX14 Health, its representatives, employees, agents, successors, and assigns from any claims, demands, or liability arising from the coaching relationship, including actions taken or not taken by the client based on coaching discussions or materials. No warranties—express or implied—are made regarding coaching services, materials, or resources provided. Coaching services, including any related content or recommendations, are offered “as is.” External Resources: RX14 Health may provide links, references, or materials from external sources for convenience. These do not constitute endorsement. Clients are solely responsible for evaluating the relevance, accuracy, and policies of any external information or services. Binding Agreement: This agreement is binding upon the client and the client’s heirs, legal representatives, and assigns. No verbal promises or agreements outside of this written document are considered valid.

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PATIENT FINANCIAL RESPONSIBILITY ACKNOWLEDGEMENT

Payment is required at the time services are rendered. This includes co-payments and payments for services not covered or denied by your insurance company. Cancellations are required 48 hours prior to the appointment. Appointments not cancelled 48 hours in advance will result in being charged for the full appointment time. This fee must be paid before a new appointment is scheduled. Declined or Returned Payments: A $100 charge will be applied to your account for any checks rejected by the bank for any reason. If a pre-arranged credit card payment plan is established and a payment declines, you may be charged $25 per

declined transaction. Please ensure that there are sufficient funds on the stored credit card to cover these payments prior to setting up payment arrangements and contact our office immediately with any changes regarding your stored card. Additional fees may be charged by your financial institution. We offer the convenience of securely storing credit or debit card numbers on file with our office. Please be assured that this payment method will in no way compromise your ability to dispute charges or question your company’s determination of payment. If you have questions about this payment method, do not hesitate to ask. I

acknowledge full financial responsibility for services rendered by RX14 Health. Should this account become delinquent, I agree to pay all collection and court costs, including attorney’s fees. All past due amounts may accrue interest at the rate of 1.5% per month, 18% per annum if the balance is not paid within 60 days. I certify that this information is true and correct to the best of my knowledge and will notify the office of any changes to my information, such as, but not limited to change in address, telephone numbers, insurance coverage, etc. I have read, understand, and agree to abide by the Financial Policy.

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WRITTEN ACKNOWLEDGEMENT FORM

Our Notice of Privacy Practices provides information about how we may use and disclose medical information about you. As provided in our notice, the terms of our notice may change. If we change our notice, you may receive a revised copy. I have been provided with a copy of RX14 Health's Notice of Privacy Practices. I have had the opportunity to read the Notice of Privacy Practices located at: https://www.rx14health.com/privacypolicy I understand that I may ask questions to RX14Health if I do not

understand any information contained in the Notice of Privacy Practices.

 

MEDIA RELEASE CONSENT

We love to be able to congratulate our clients on a job well done and support their career via social media, education and publication. By signing below, I consent for photographs and/or video images to be used for purposes of marketing (website, print, digital or social media). By consenting to photographs and/or video images I understand I will not be compensated from any party. I authorize the release of the following information like first and last name, location, title, services used, testimony as well as public information to be used. I further acknowledge that my participation is voluntary and agree that use of any photographs and/or video images confers no rights of ownership or royalties whatsoever. I hereby release RX14 Health and

Amanda Miller and its employees, and any third parties involved in the creation of or publication of educational or marketing materials, from liability for any claims by me or any third party in connection with my participation. I confirm understanding of this consent. If I wish to withdraw my consent in the future, I may do so via written request submitted to RX14 Health or by completion of a new form.

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DISCLOSURE TO PRIVATE HEALTH INFORMATION

Information related to my health may be disclosed as needed for payment of health care services. I understand that RX14 Health will only disclose information relevant to my current treatment that is critical for processing.

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SUBSCRIPTION SERVICE

1. Overview: By enrolling in an RX14 Health membership plan (Signature, Select, or Maintenance Rx), you (“Member”) agree to the following terms and conditions governing your subscription, billing, communication, and use of services. RX14 Health delivers direct, personalized care but is not health insurance.

2. Nature of Membership: Your subscription provides access to the services specifically listed within your selected plan. Services include virtual visits, messaging access, medication management, chronic care management, and select acute care depending on the tier.

Memberships are not transferable, and services may only be used by the enrolled member.

3. Payment & Billing- Subscription Fees. You authorize RX14 Health to charge the payment method you provide for the following:

• Signature Concierge – $150/month or $1,650/year

• Select Concierge – $95/month or $1,045/year

• Maintenance Rx – $40/month or $480/year

• Single Visit – $175 per 60-minute visit

Prices may be updated with 30 days’ notice.

4. Recurring Billing

• Monthly plans auto-renew every 30 days.

• Yearly plans auto-renew every 12 months.

• Charges occur automatically until you cancel in writing.

5. Billing Failures. If your payment method fails, RX14 Health may pause services until payment is updated.

6. Cancellation Policy: You may cancel your subscription anytime with written notice via email or the patient portal.

• Monthly plans: cancellation takes effect at the end of the current billing cycle.

• Yearly plans: cancellations are effective at term end; refunds are not provided for unused months.

• No refunds for past services or unused visits.

7. Scope of Care. Your plan includes the services outlined in the membership comparison chart. This may include:

• Medication management

• Chronic care management

• Health optimization and performance care (specific tiers)

• Acute/sick visits (varies by tier)

• Virtual visits (frequency varies by tier)

• Asynchronous messaging (priority or standard depending on plan)

Not Included:

• Emergency services

• Specialist care

• Imaging, labs, procedures

• In-person visits

• Controlled substance management

• Care outside the scope of PA practice laws in covered states

A separate fee may apply for services not included in your chosen plan.

8. . Communication & Access. RX14 Health offers messaging access based on your membership tier.

• Priority Messaging: Signature

• Standard Messaging: Select

• Refill-Only Messaging: Maintenance Rx

9. Messages may be used for clinical questions, follow-ups, and care coordination. Messaging is not monitored 24/7 and should never be used for emergencies.

10. Intake Requirements

• Signature & Select: No intake required.

• Maintenance Rx: A one-time initial intake visit is required before subscription services begin.

• Single visit: No intake required unless clinically indicated

11.  Emergency Disclaimer RX14 Health does not provide emergency medical care.
For symptoms such as chest pain, severe shortness of breath, stroke symptoms, severe injury, mental health crisis or urgent concerns, call 911or go to the nearest emergency department.

12. Insurance & Reimbursement: RX14 Health does not bill insurance. Membership fees are paid directly and may not be reimbursable. You may submit invoices to your insurance or HSA/FSA case-by-case. A superbill can be provided for you to submit to your insurance independently. 

13. Member Responsibilities: By enrolling, you agree to:

• Provide accurate medical history

• Use services appropriately and honestly

• Update payment information as needed

• Follow medical recommendations

• Notify RX14 Health of any major health changes

14. Privacy & HIPAA: RX14 Health complies with all federal and state privacy regulations, including HIPAA. Your information is secure and will not be shared without your consent except as legally required. RX14 Health may communicate with you through HIPAA-compliant messaging systems, telehealth platforms, and encrypted email when appropriate.

15. Telemedicine Consent: By enrolling, you consent to receive medical care via telemedicine. You understand the risks, benefits, and limitations of virtual care.

16. Termination of Membership by RX14 Health: RX14 Health reserves the right to terminate a membership for:

• Nonpayment

• Abusive or inappropriate behavior

• Misuse of messaging or telemedicine

• Care needs falling outside the scope of practice

• Safety concerns

• Any other reason deemed appropriate by RX14 Health

17. If terminated, prorated refunds for yearly memberships will be considered on a case-by-case basis if no services were rendered during that period.

18. Limitation of Liability: RX14 Health is not liable for delays, platform outages, or limitations inherent to telemedicine. Your membership does not guarantee specific outcomes.

19. Agreement: By completing checkout, enrolling in a membership, or initiating payment, you acknowledge and agree to all terms in this Subscription Agreement.

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I understand and agree with the above notices, and consent to using telehealth services at RX14 Health.