Appendix 1

Services and Payment Terms

1.Medical Services. As used in this Agreement, the term Medical Services shall mean those medical services that the Physician herself is permitted to perform under the laws of the State of Georgia and that are consistent with her training and experience as an internal medicine physician, as the case may be. Patient shall also be entitled to an annual in-depth “wellness examination and evaluation,” which shall be performed by the Physician, and include the following:•Health Risk Assessment • Vision and Hearing Screening • EKG • Comprehensive Lab Screening*• Psycho Social Screening • Custom Wellness Plan to Include Exercise and Dietary Plan

*Some restrictions apply

The Physician may from time to time, due to vacations, sick days, and other similar situations, not be available to provide the services referred to above in this paragraph 1. During such times, Patient’s calls to the Physician, or to the Physician’s office, will be directed to a physician who is “covering” for the Physician during his absence. Braun Internal Medicine, P.C. will make every effort to arrange for coverage but cannot guarantee such coverage.

2.Non-Medical, Personalized Services. Braun Internal Medicine, P.C. shall also provide Patient with the following non- medical services (“Non-Medical Services”):

(a)24/7 Access. Patient shall have access to the Physician via instant messaging and video chat. Patient shall also have direct telephone access to the Physician on a twenty-four hour per day, seven-day per week basis. Patient shall be given a phone number where patient may reach the Physician directly around the clock. During the Physician’s absence for vacations, continuing medical education,illness, emergencies, or days off, Phoenix DPC will provide the services of an appropriate licensed healthcare provider for assistance in obtaining medical services. Patient shall be given instructions as to how to contact such healthcare provider. Such provider shall be available to Patient to the same extent as would the Physician, however provider shall be contacted through an answering service rather than through a direct phone line.

(b)E-Mail Access. Patient shall be given the Physician’s e-mail address to which non-urgent communications can be addressed. Such communications shall be dealt with by the Physician or staff member of the Practice in a timely manner. Patient understands and agrees that email and the internet should never be used to access medical care in the event of an emergency, or any situation that Patient could reasonably expect may develop into an emergency. Patient agrees that in such situations, when a Patient cannot speak to Physician immediately in person or by telephone, that Patient shall call 911 or the nearest emergency medical assistance provider, and follow the directions of emergency medical personnel.(c)No Wait or Minimal Wait Appointments. Every effort shall be made to assure that Patient is seen by the Physician immediately upon arriving for a scheduled office visit or after only a minimal wait. If Physician foresees a minimal wait time, Patient shall be contacted and advised of the projected wait time.
(d)Same Day/Next Day Appointments. When Patient calls or e-mails the Physician prior to noon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort shall be made to schedule an appointment with the Physician on the same day. If the patient calls or e- mails the Physician after noon on a normal office day (Monday through Friday) to schedule an appointment, every reasonable effort shall be made to schedule Patient’s appointment with the Physician on the following normal office day. In any event, however, Braun Internal Medicine, P.C. shall make every reasonable effort to schedule an appointment for the Patient on the same day that the request is made.(e)Visitors. Family members* temporarily visiting a Patient from out of town may, for a two- week period, take advantage of the services described in sub-paragraphs (a), (c), and (d) of this paragraph. Medical services rendered to Patient’s visitors shall be charged on a fee-for-service basis.

*Family members who are Medicare beneficiaries must be covered

by a Medicare opt out and waiver agreement in order to be treated
by a Braun Internal Medicine, P.C. Physician.

(f) Specialists. Braun Internal Medicine, P.C. Physician shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the Phoenix DOC Physician.

3. Membership Fees. Patient shall pay a registration fee of $99 due upon execution of this agreement. Registration fees are capped at $198.00 per family if kids are minors and are living with the parents at time of sign up.

Monthly membership fees are:

(a) 13-20 years of age: $10 per month if at least one parent is a member
or $59 per month if no parent is a member, (b) 21-44 years of age: $59
per month, (c) 45-64 years of age: $79 per month, (d) 65 years of age
and older: $99 per month. The first month’s membership payment is due on first visit or other service rendered to the patient or on elected draft date, whichever occurs first.

Appendix 2

Medicare Opt Out
Agreement

This agreement (“Agreement” ) is entered into by and between Braun Internal Medicine, P.C., a Georgia professional corporation, owned and operated by Dr Heidi M Braun, MD, (the “ Physician” ),
whose principal medical office is located at 114 Canal St. Ste 502, Pooler, GA 31322 and, a beneficiary enrolled in Medicare Part B
(“ Beneficiary” ), who resides at , , ________/Georgia .

Introduction

The Balanced Budget Act of 1997 allows physicians to “opt out” of Medicare and enter into private
contracts with patients who are Medicare beneficiaries. In order to opt out, physicians are required
to file an affidavit with each Medicare carrier that has jurisdiction over claims that they have filed
(or that would have jurisdiction over claims had the physicians not opted out of Medicare). In
essence, the physician must agree not to submit any Medicare claims nor receive any payment
from Medicare for items or services provided to any Medicare beneficiary for two years.

This Agreement between Beneficiary and Physician is intended to be the contract physicians are
required to have with Medicare beneficiaries when physicians opt-out of Medicare. This
Agreement is limited to the financial agreement between Physician and Beneficiary and is not
intended to obligate either party to a specific course or duration of treatment.

Physician Responsibilities

(1) Physician agrees to provide Beneficiary such treatment as may be mutually agreed upon and at mutually agreed upon fees.

(2) Physician agrees not to submit any claims under the Medicare program for any items or services, even if such items or services are otherwise covered by Medicare.

(3) Physician agrees not to execute this contract at a time when Beneficiary is facing an emergency or urgent healthcare situation.

(4) Physician agrees to provide Beneficiary with a signed copy of this document before items or services are furnished to Beneficiary under its terms. Physician also agrees to retain a copy of this document for the duration of the opt-out period.

(5) Physician agrees to submit copies of this contract to the Centers for Medicare and

Medicaid Services (CMS) upon the request of CMS.

Beneficiary Responsibilities

(1) Beneficiary agrees to pay for all items or services furnished by Physician and understands that no reimbursement will be provided under the Medicare program for such items or services.

(2) Beneficiary understands that no limits under the Medicare program apply to amounts that may be charged by Physician for such items or services.

(3) Beneficiary agrees not to submit a claim to Medicare and not to ask Physician to submit a claim to Medicare.

(4) Beneficiary understands that Medicare payment will not be made for any items or services furnished by Physician that otherwise would have been covered by Medicare if there were no private contract and a proper Medicare claim had been submitted.

(5) Beneficiary understands that Beneficiary has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that Beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered items and services furnished by other physicians or practitioners who have not opted out of Medicare.

(6) Beneficiary understands that Medigap plans (under section 1882 of the Social Security Act) do not, and other supplemental insurance plans may elect not to, make payments for such items and services not paid for by Medicare.

(7) Beneficiary understands that CMS has the right to obtain copies of this contract upon request.

Medicare Exclusion Status of Physician

Beneficiary understands that Physician has not been excluded from participation under the
Medicare program under section 1128, 1156, 1892, or any other sections of the Social Security
Act.

Duration of the Contract

This contract becomes effective on , 2017, and will continue in effect
until , 2018. Either party may terminate treatment with reasonable notice
to the other party. Notwithstanding this right to terminate treatment, both Physician and
Beneficiary agree that the obligation not to pursue Medicare reimbursement for items and
services provided under this contract will survive this contract.

Successors and Assigns

The parties agree that this agreement will be fully binding on their heirs, successors, and assigns.

Physician and Beneficiary intend to be legally bound by signing this agreement on the date set forth below.

Dr Heidi M Braun, MD

Braun Internal Medicine, P.C., 2017

Date Signed by Physician and Professional Corporation

Name of Beneficiary (printed)

Signature of Beneficiary

Date Signed