Member Terms of Agreement
MEMBERS TERMS OF AGREEMENT
CONFIRMATION AND REPRESENTATIONS. I enter into this Terms of Agreement (“Agreement”) with CoPayAssistRx, LLC (the “Company”) so that I may obtain access to medically-necessary and lawfully prescribed medications (the “RX”). Intending to be legally bound herby, I agree:
- I am at or above the age of majority in the United States, in the jurisdiction in which I currently reside and where I am entering into this Agreement.
- I am not restricted from making my own medical decisions under the laws of the jurisdiction in which I currently reside.
- I certify that I am a resident and citizen of the United Sates and not a resident or citizen of any other country.
- I am under the care of a duly qualified and licensed physician in the United States (my “S. Physician”) and the RX was prescribed for me was prescribed by my U.S. Physician.
- My S. Physician has examined me within the last twelve (12) months, has confirmed the medical need for the RX, and will examine me at least once every twelve (12) months while I am taking the RX.
- Any RX that I ask Company to assist me in obtaining is a prescription medication that I have been prescribed before entering this Agreement and have used, under my S. Physician’s orders and supervision, with no adverse health consequences for at least thirty (30) days prior to placing an order for the RX through Company.
- S. Physician is providing me ongoing care, and I do not seek and will not rely on any medical information or advice from Company or any Company selected pharmacist physician or medical provider.
- I have not violated any laws in the jurisdiction in which I currently reside (or, if different, in the jurisdiction in which the prescription was issued) in obtaining the prescription for the RX.
- The prescription issued by my S. Physician for the RX which, I order pursuant to this Agreement, has not been altered in any way nor has the prescription been filled previously.
- I will use any RX obtained for me through Company strictly in accordance with the instructions provided by my S. Physician, and I will not order more than a 90-day supply or use the RX for anything other than personal use.
- I will not permit anyone else to use the RX.
- In the event that I suffer any side effects from any RX, I will immediately contact my S. Physician or appropriate emergency responders.
- All information that I provide to Company is and shall be true and correct with no material or substantive omissions.
AUTHORIZATION AND CONSENT. I consent to and authorize the following:
- I hereby appoint Company and its employees, agents, delegates, contractors, and independent contractors (collectively, “Company Parties”) as my agents and attorneys-in-fact for the purposes of: (1) obtaining RXs which correspond to the prescriptions issued by my S. Physician; (2) selecting physicians, pharmacies, and other professionals as necessary to serve me outside the U.S.; and (3) arranging for pharmacies to dispense to me the RXs as prescribed.
- Company Parties may perform any act that I could myself perform in having my prescription reviewed by any physician, pharmacist, or pharmacy technician and in having the RX dispensed by a pharmacy and delivered to me by mail.
- Company Parties may arrange the purchase and delivery of the medications prescribed to me, on the terms set forth in this Agreement, as if I personally took such action, but I, not Company Parties, am the legal importer of the RX and responsible for complying with all legal requirements and associated costs.
- I authorize and instruct my S. Physician to release to Company (and any Company selected physician, pharmacist, and pharmacy technician) any and all personal medical information pertaining to me (“PMI”), including but not limited to all medical records, medical reports, progress notes, nurses’ notes, reports on diagnostic tests, medical opinions, X-ray records, imaging records, laboratory reports, and/or any other knowledge or information which my U.S. Physician may possess.
- I agree to instruct my S. Physician to issue my prescription on paper (if necessary for dispensing by a pharmacy located outside my U.S. Physician’s jurisdiction) and to send the original signed copy of the prescription (by mail, by fax, via the internet or otherwise) to Company from my U.S. Physician’s office, and to pay for any associated costs.
- Company and its selected physicians, pharmacists, and pharmacy technicians may contact my S. Physician to discuss my prescription and the RX.
- Company selected physicians may issue prescriptions for medications I have ordered if the physicians deem it advisable and appropriate. However, I acknowledge my S. Physician is my primary physician, and the only source of medical advice I will rely on, excluding physicians I am referred to in the United States and physicians I self-refer to in the United States.
- Company may make payments on my behalf to pharmacies for dispensing medicine in accordance with my RX and physicians for services rendered on my behalf.
- I request and authorize my employer or plan holder, as my appointed agent, to pay for all products and services relating to the RX medicine that I obtain through Company in such amounts as are found appropriate by my employer or plan holder in accordance with the benefits plan.
ACKNOWLEDGE AND RELEASE. I hereby make the following acknowledgements and releases to Company and Company Parties, including physicians, pharmacists, pharmacy technicians, nurses, receptionists, and staff used by Company to facilitate the terms of this Agreement, that my assigns, heirs, and all others who may claim by or through me at any time shall be bound hereby and:
- My S. Physician is my primary physician. Any Company selected physician is being asked to review the information contained in my PMI only for the purpose of authorizing the RX prescribed for me by my U.S. Physician to be dispensed to me by a Company selected pharmacy.
- Company has made no representations or warranties to me, including, without limitation, representations or warranties regarding the use or fitness for any particular purpose for the RX delivered (including, without limitations, the RX’s appropriateness for curing or helping relieve any particular ailment, illness or disease, or the RX’s potential or actual side effects or adverse effects whether previously known or unknown). I accept and use the RX at my sole risk, with the full knowledge and understanding that using an RX supplied by a foreign pharmacy could result in death, injury or permanent disability.
- I wish to obtain a prescription and/or RX from a Company selected physician and have enlisted the services of Company to facilitate this Agreement. I understand that a Company selected physician will rely on the accuracy of the examination performed, and the prescription provided, by my S. Physician.
- I release and hold harmless and indemnify Company and all of its officers and directors, agents, delegates, employees, contractors and independent contractors from any and all liability, claims, and causes of action with respect to the errors, omissions or negligence of Company or negligence, errors or omissions of the Company selected physician, pharmacy, agent or agency responsible for fulfilling or transporting my order.
- I acknowledge that I have purchased my RX internationally for personal use and understand that my RX may be subject to U.S. border inspection. I specifically confirm, acknowledge and agree that title to my RX passes to me when my RX is shipped from the Company selected pharmacy.
- I acknowledge that Company, as my paid agent, requires payment in full prior to shipment and that my order may not be returned for a refund or an exchange.
- I acknowledge I am the legal importer of the RX and I am responsible for all the legal requirements, costs, incidental related expenses and for any fines, penalties or taxes owed that may be due as a result of my order.
- I will not modify or alter in any way any documentation created by my S. Physician or my U.S. Physician’s office. I will be responsible for cancelling any duplicative prescriptions that may exist or may have been sent to a United States pharmacy that would be duplicative of the RX.
- Company may receive and collect any and all information about me and my health, including but not limited to my full name, address, telephone number, e-mail address, Social Security Number, PMI, and payment information (collectively also “PMI”), and may maintain such information on file as necessary to verify and process future orders and to obtain payment and reimbursement for them. Company and Company selected physicians and pharmacists may share any and all information received from or about me with my S. Physician, Company selected physicians and pharmacists, and my employer or benefits plan administrator, and their respective employees, delegates, contractors, agents and independent contractors, for the purposes of obtaining the RX as prescribed for me and of obtaining proper payments for the RX and related services.
- I am aware that Company may transmit my PMI by electronic means (for example fax, electronically or via the internet) to anyone Company determines is selected or required to facilitate my order. I understand that the use of electronic means will enhance the efficiency and timeliness of processing my order. I also understand that Company, as a custodian of my PMI, will take all appropriate precautions to protect my PMI from improper disclosure or use. I hereby consent to Company’s transmission of my PMI by electronic means to its employees, delegates, contractors, agents and independent contractors, selected physicians, and pharmacies.
FURTHER ACKNOWLEDGEMENT & RELEASE. I hereby make the following further acknowledgement and agree this Agreement shall be binding on my heirs, executed administrators, other legal representatives and all others who may claim by or through me at any time that:
- I acknowledge that the plan holder or Company has made no representations or warranties to me, including without limitation, representations or warranties regarding the use for any particular purpose the RX delivered, including without limitations, the RX’s appropriateness for curing or helping relieve any particular ailment, illness or disease or the RX’s potential or actual side or adverse effects whether previously know or unknown.
- I acknowledge that child protective packaging may not be used in filling my prescription. I promise that upon my receipt of the medicine I will take all steps necessary to prevent any child from having unauthorized access to the medicine. I hereby release Company and all its officers, directors, agents, delegates, employees, and contractors, including the pharmacy that fills my prescription, from an and all claims arising from or relating to the use of, or failure to use, child protective packaging.
- I release the plan holder and its officers, employees, agents, heirs, successors, executors, administrators, spouse, agents, representatives and assigns from (I) any and all causes of actions with respect to negligence, errors or omissions by the plan holder, Company and agency responsible for fulfilling or transporting my order; (II) any and all causes of actions with respect to negligence errors or omissions by Company in obtaining the prescription medications to fill my order; (III) any and all causes of actions regarding the sue for any purpose whatsoever of any medications delivered through this program except with regard to gross negligence, willful misconduct or intentional acts.
This Agreement shall be construed and interpreted according to the laws of the state of Delaware. Any and all claims or disputes arising from this Agreement shall be submitted to binding arbitration in accordance with, and administered by JAMS. The parties further acknowledge that arbitration shall be held in Louisville, Kentucky and submit to the jurisdiction and venue of Jefferson County, Kentucky for submission of the decision of the arbitration and for any other claims or causes of action that may arise from this Agreement that are not resolved by arbitration. The PARTIES HEREBY IRREVOCABLY WAIVE ANY AND ALL RIGHTS TO A JURY OR TRIAL IN ANY LEGAL PROCEEDING ARISING OUT OF OR RELATED TO THIS AGREEMENT OR THE TRANSACTIONS CONTEMPLATED HEREBY.