MEMBERSHIP AGREEMENT FOR ONGOING PSYCHIATRIC CARE - REVISED April 24, 2026

THIS AGREEMENT FOR MEMBERSHIP ("Agreement"), dated and effective as of the date the patient completes/ submits enrollment forms, is by and between A Plus Psychiatry, LLC, an Ohio limited liability company ("Practice") and the patient (or parent/guardian if the patient is a minor) ("Client") that is being enrolled, each individually a "Party" and collectively referred to as the "Parties."

RECITALS

WHEREAS, Practice provides psychotherapy, medication management, and evaluation and management services via telemedicine to individuals to promote and support mental health and wellness; and

WHEREAS, Practice provides ongoing psychiatric care to clients using a direct pay membership model in which clients receive the services described in this Agreement in exchange for payment of periodic fees; and

WHEREAS, Client desires to engage Practice to provide the services as provided in this Agreement, and Practice agrees to provide the services.

NOW, THEREFORE, in consideration of the mutual promises contained herein, the Parties agree as follows:

1. Services.

Client hereby engages Practice to provide psychiatric evaluation and management services (the "Services") to Client:

(a) New Member Psychiatric Assessments and Ongoing Membership-based Services.

(i) Before enrolling in ongoing membership-based services (the "A+ Membership Plan"), Client must undergo a one-time new Client psychiatric assessment that shall be approximately ninety (90) minutes in duration and includes a psychiatric assessment, a determination if ongoing membership-based care is appropriate, treatment planning, and a question-and-answer session. Medications may be prescribed as part of the new Client psychiatric assessment in the sole discretion of Practice. In the event Practice previously completed a one-time diagnostic evaluation/consultation for patient, Practice, in its sole discretion, may waive the new Client psychiatric assessment.

(ii) Upon completion of Client's psychiatric assessment, if the Practice, in its sole discretion, determines that ongoing membership-based care is appropriate, Practice will provide Services, including but not limited to, psychiatric treatment such as psychotherapy, psychoeducation, medication management, and imaging and laboratory orders. Practice will also provide varying non-medical services such as after-hours access, same or next day appointments, and coordination with specialists.

(b) Methodologies.

The methodologies utilized in performing the Services may vary depending on the needs of the Client and the particular concerns Client is experiencing. There are many different methodologies that Practice may use in treating Client, including but not limited to, a non-structured interview with Client and family members (where applicable), as well as review of collateral information such as previous medical and psychiatry evaluation and treatment notes, prescription medication history, and rating scales. Psychoeducation and psychotherapeutic techniques may also be utilized as part of the process. Psychotherapy calls for an active effort on Client's part, and may involve discussing uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. There are no guarantees of what Client may experience. In order to provide safe and accurate diagnosis and treatment recommendations, Client, to the best of his or her ability, agrees to provide Practice with complete and accurate information related to Client's medical history, condition(s), and current or previous medical care.

(i) Limitations.

The Services do not include any care or treatment beyond the Services defined within this Agreement, including but not limited to, forensic evaluations; evaluations related to custody disputes, disability, worker's compensation, neuropsychiatric evaluations (intellectual disability, dementia, dyslexia, learning disability, etc.); or situations where the standard of care for in-person visits cannot be met, such as severe communication limitations. Client must sign and meet the Practice's Informed Consent for Telemedicine Services prior to the provision of any Services.

Practice and Client will have ongoing outpatient telemedicine and/or in-person appointments, based on Practice's determination of clinical appropriateness, at a frequency and duration as determined by Practice.

(d) Contacting Practice.

Practice may be contacted by phone at 330-542-8634 or e-mail at clinic@apluspsychiatry.com. Practice will attempt to respond to urgent calls and e-mails from Client within a reasonable timeframe, provided Client acknowledges that in the event of a medical or mental health emergency, Client should dial 911.

(e) Rescheduling Appointments.

Client shall provide a minimum of twenty-four (24) business hours notification to cancel or reschedule Client's assessment or appointment via phone, text, or e-mail with electronic receipt requested to clinic@apluspsychiatry.com.

(f) Confidentiality.

Client understands that the law protects the privacy of certain communications between a patient and a psychiatrist. In most situations, Practice may only release information about Client's treatment to others if Client signs a written authorization that meets specific legal requirements. However, Client understands and provides consent for Practice to release information about Client's treatment to other individuals in the following circumstances: (1) when Practice is formally consulting with another health care professional about Client; and (2) if Practice believes that Client needs emergency care. Further, Client understands that Practice may have a legal obligation to disclose Client's treatment information without Client's consent in certain circumstances, including but not limited to: (1) if Client is involved in a court proceeding and a court order mandates the disclosure of information concerning the professional services rendered to Client; (2) if a government agency is requesting the information for health oversight activities; (3) if Client files a lawsuit against Practice; or (4) in order to meet mandated reporting requirements.

(i) The laws regarding health care and confidentiality in minors are complex. Permission of parents or authorized representatives may be necessary in order to request or release information about them. The parent/authorized representative has the right to access all parts of their clients record unless prohibited by court, statute, or rules. Please note that federal law allows a minor to refuse to consent to any communication with a parent or guardian about treatment for substance use disorders, unless the minor provides a signed authorization form. Under Ohio law, upon the request of a minor fourteen (14) years of age or older, Practice may provide outpatient mental health services, excluding the use of medication, without the consent or knowledge of the minor's parent or authorized representative. The minor's parent or authorized representative will not be informed of the outpatient mental health services without the minor's consent unless Practice determines there is a compelling need for disclosure based on a substantial probability of harm to the minor or to other persons, and if the minor is notified of the Practice's intent to inform the minor's parent, or authorized representative.

(g) Medical Records.

Practice will maintain copies of Client's medical records. Practice will use reasonable efforts to respond in a timely manner to written requests from Client for access to, or copies of, Client's medical records submitted by e-mail with electronic receipt requested to clinic@apluspsychiatry.com. Under Ohio law, Client may be charged a sliding-scale fee for copies of paper or electronic records. The most-recent fees are set forth at: https://odh.ohio.gov/home/mrpi.

2. Term.

Unless otherwise set forth in a separate written agreement signed by the Parties, the term of this Agreement shall commence as of the Effective Date and shall continue for a period of one-year. This Agreement shall automatically renew annually for additional one-year terms, unless terminated earlier pursuant to the terms of this Agreement.

3. Financial Terms and Conditions.

Client agrees to be wholly responsible for, and to pay the costs of, Services provided by Practice. The applicable prices are set forth at: https://www.apluspsychiatry.com, and subject to change.

(a) Because Client is wholly responsible to pay for Services provided by Practice, Client will provide a credit or debit card to Practice prior to the provision of any Services. Client hereby authorizes Practice to charge Client's credit or debit card for any Services that are provided, unless other arrangements have been made.

(b) Payment for the new client psychiatric assessment is due and payable upon execution of this Agreement, and prior to the start of the assessment. Monthly membership fees for the A+ Membership Plan are due no later than the first of each month, unless both parties may agree to different billing day per month. Client acknowledges that A+ Membership Plan fees must be paid in full each month before receiving services. Monthly membership fees may vary depending on whether Client is determined by Practice, in its sole discretion. Membership fees for Client's initial month receiving Services under this Agreement may be prorated based on the Effective Date of this Agreement.

(c) Client understands and agrees that the fees charged by Practice do not include the costs of any medications, treatments, procedures, services, or products provided by other entities or individuals that may be prescribed or recommended by Practice in connection with this Agreement. Client may receive one or more separate bills for such medications, and/or other treatments, procedures, services, or products and Client agrees that Client is wholly responsible for payment of such bills. Client further understands and agrees that such other entities and individuals will have their own billing and collection practices. Client agrees to hold Practice harmless in connection with the costs of any medications, or other treatments, procedures, services, or products provided by other entities or individuals.

(d) Client acknowledges that Client is wholly responsible for full payment of fees for the Services regardless of whether the Client actually attends or completes the new member psychiatric assessment or any scheduled appointments, or if Practice terminates this agreement for cause.

4. Provider Absence.

Services may be temporarily unavailable from time to time, due to such things as vacations, illness, or personal emergency. When the date/s of such absences are known in advance, Practice shall give notice to Clients so that they may schedule non-urgent care accordingly. During unexpected absences, Clients with scheduled appointments shall be notified as soon as practicable, and appointments shall be rescheduled at the Client's convenience. If the Client experiences an acute medical issue requiring immediate attention during any such absence, Client should immediately dial 911 or go immediately to the nearest hospital emergency room. Charges from a hospital emergency room or any other outside provider are not included under this Agreement and are the Client's responsibility.

5. Monthly Fee and Service Offering Adjustments.

In the event that the Practice finds it necessary to increase or adjust monthly fees or Service offerings before the termination of the Agreement, the Practice shall give notice of the same by providing notice to Client's e-mail address on file 30 days prior to any increase or adjustment. If Client does not consent to the modification, Client shall terminate the Agreement prior to Client's next scheduled monthly payment by submitting a notice of termination by e-mail with electronic receipt requested to clinic@apluspsychiatry.com.

6. Reinstatement (Re-enrollment) and Third-Party Payor Authorizations.

In the event Client terminates enrollment in the A+ Membership Plan, Practice will require Client to pay a reinstatement fee upon future re-enrollment in the A+ Membership Plan. Upon any re-enrollment, Client agrees to execute a new Membership Agreement prior to receiving Services. The terms of any new Agreement may differ from the prior Agreement, including but not limited to fees, services offered, and cancellation policies.

6(a). Third-Party Payor Authorization (Adult Clients Without Legal Guardian).

In the event that Client is an adult (age eighteen (18) or older) without a legal guardian, and a third party ("Sponsor") is designated as the payor for Client's membership fees, the following terms and conditions shall apply:

(a) Sponsor Authorization Agreement Required.

Client acknowledges and understands that any Sponsor designated to pay for Client's membership must execute a separate Third-Party Payor Authorization Agreement with Practice prior to the commencement or continuation of Services under this Membership Agreement. Client's membership cannot commence, continue, or be renewed without a fully executed Third-Party Payor Authorization Agreement on file with Practice.

(b) Sponsor's Limited Authority.

By executing the Third-Party Payor Authorization Agreement, Sponsor is authorized to authorize charges to Sponsor's payment method for Client's monthly membership fees and to request changes to Client's membership status, including but not limited to pausing, resuming, or terminating the membership, subject to the terms and conditions of the Third-Party Payor Authorization Agreement. Sponsor is authorized to receive communications from Practice regarding membership billing and account status only.

Client understands that this Membership Agreement is a direct agreement between Client and Practice. Client's clinical care, treatment decisions, clinical recommendations, diagnoses, and confidentiality protections are governed by this Agreement and by applicable federal and state law, including but not limited to the Health Insurance Portability and Accountability Act (HIPAA) and Ohio state law. Sponsor's role as payor does not grant Sponsor any right to access Client's medical records, treatment information, mental health diagnoses, or progress notes, except as expressly permitted by applicable law or by Client's separate written authorization. Sponsor shall not have authority to override Client's clinical decisions, consent to or refuse treatment on Client's behalf, or to override Client's medical decision-making rights.

(c-1) Third-Party Payor Authorization for PHI Disclosure.

In the event that Client designates a Sponsor to pay for Services, Client acknowledges that Client will be required to execute a separate Health Insurance Portability and Accountability Act (HIPAA) authorization permitting Practice to disclose protected health information to Sponsor for purposes of billing and care coordination. Client understands that Practice will make reasonable attempts to limit disclosure to information necessary for these purposes and will not over-share clinical information.

(d) Termination of Membership by Sponsor.

In the event that Sponsor requests termination of Client's membership, Practice shall notify Client in writing that the membership has been terminated or will be terminated, and shall provide Client with written notice of the following options available to Client:

(i) Self-Pay Membership Option.

Client may elect to continue membership and continue paying the monthly membership fees by authorizing Practice to charge Client's own credit or debit card directly. If Client elects this option, Client must provide written authorization to charge Client's payment method to Practice, and Client shall be entirely responsible for all monthly membership fees. Practice will provide Client with current membership fee pricing at https://www.apluspsychiatry.com.

(ii) Fee-for-Service Option.

Client may elect to continue receiving psychiatric care and Services from Practice on a fee-for-service basis rather than under the membership model. If Client elects this option, Client agrees to pay for each visit and service as billed by Practice at the applicable fee-for-service rates set forth at https://www.apluspsychiatry.com. Client must authorize Practice to charge Client's own credit or debit card for any Services provided. Client shall be entirely responsible for all charges incurred.

(iii) Discontinuation of Care.

Client may choose to discontinue the Client's relationship with Practice entirely.

(e) Client's Financial Responsibility Upon Continuation.

If Client elects to continue Services under either option (d)(i) (Self-Pay Membership) or option (d)(ii) (Fee-for-Service), Client acknowledges and agrees that Client is entirely responsible for all charges, fees, and costs associated with Services rendered. Client will authorize Practice to charge Client's payment method directly. Client further acknowledges that Practice will not submit bills or seek reimbursement from Sponsor for any Services rendered after Sponsor's termination of the membership, and that Sponsor shall have no further financial obligation for any Services provided unless Sponsor provides separate written authorization and payment arrangement.

(f) Practice's Right to Decline Continuation.

Practice reserves the right, in its sole discretion, to decline to continue providing Services to Client on a fee-for-service basis or as a self-paying member at any time and for any reason. In the event Practice declines to continue Services, Practice shall provide Client with written notice of such decline and shall make reasonable efforts to refer Client to another qualified mental health professional with appropriate scope of practice for Client's presenting concerns.

(g) Reinstatement Following Termination by Sponsor.

In the event that Client's membership is terminated by Sponsor and Client does not elect to continue care under option (d)(i) or (d)(ii) above, and Client later wishes to resume membership with Practice, Client shall be required to execute a new Membership Agreement and, if applicable, a new Third-Party Payor Authorization Agreement. Client shall be subject to the payment of any applicable reinstatement fees in accordance with Section 6 of this Agreement.

7. Non-Participation in Insurance.

Client agrees not to submit a claim, bill to, or seek reimbursement from any public health program (i.e. Medicare, Medicaid, Tricare, Veterans Affairs and Federal Benefits) or any private health insurance plan or worker's compensation plan for any Service received pursuant to this Agreement. Client also understands that Practice will not submit a claim, bill, or request for payment to any public health program (i.e. Medicare, Medicaid, Tricare, Veterans Affairs and Federal Benefits) or any private health insurance plan or worker's compensation plan for any Service received pursuant to this Agreement. Furthermore, if Client is eligible or becomes eligible for any public health program (i.e. Medicare, Medicaid, Tricare, Veterans Affairs and Federal Benefits) during the term of this Agreement, the Client agrees to immediately inform the Practice by e-mail with electronic receipt requested to clinic@apluspsychiatry.com.

8. This Agreement is not Health Insurance.

Client has been advised and understands that this Agreement is not an insurance plan. It does not replace any health coverage that the Client may have, and it does not fulfill the requirements of any federal health coverage mandate. This Agreement does not include hospital services, emergency room treatment, or any services not personally provided by the Practice or its providers. This Agreement includes only those Services identified in Section 1 above. If a Service is not specifically listed in this Agreement, it is expressly excluded from this Agreement. If applicable, Client acknowledges that he or she has been advised by Practice to obtain health insurance that will cover catastrophic care and other services not included in this Agreement.

9. Email and Text Messaging.

Client understands and agrees that Client is responsible for having access to a working internet connection and a device such as a telephone, tablet, or computer with video and audio capabilities to facilitate provision of Services under this Agreement. By providing an email address and cell phone number to Practice, Client authorizes Practice and its providers to also communicate with Client by email and/or text message. Client further understands and agrees that:

(a) Practice is not liable for delayed or undelivered email or text messages, or for the security of email or text messages sent by, received by, or stored on Client's personal devices or the devices belonging to Client's authorized representative(s).

(b) Practice is not responsible for any incorrect information provided to Practice, including incorrect email addresses or phone numbers, and Client must notify Practice at once if Client or Client's authorized representative changes email addresses or phone numbers, loses a phone or other personal device, suspects that the security of a phone or other personal device has been compromised in any way, or Client wishes to add or delete someone authorized to send/receive emails or text messages on Client's behalf.

(d) Email and text messaging are not appropriate means of communication in a medical or mental health emergency, for addressing time-sensitive matters, or for disclosing sensitive information. Therefore, in a medical or mental health emergency, or a situation that could reasonably be expected to develop into such an emergency, Client agrees to dial 911 or go to the nearest emergency care facility.

10. Carrier Lines.

In connection with access to and provision of Services by Practice, Client acknowledges that such services will be provided over various facilities and communications lines, and that information may be transmitted over local exchange and internet backbone carrier lines and through routers, switches, and other devices ("Carrier Lines") owned, maintained, and serviced by third-party carriers, utilities, and internet service providers, all of which are beyond Practice's control. Practice assumes no liability for or relating to the integrity, privacy, security, confidentiality, or use of any information while it is transmitted on the Carrier Lines, or for any delay, failure, interruption, interception, loss, transmission, or corruption of any data or other information attributable to transmission on the Carrier Lines. Use of the Carrier Lines is solely at Client's own risk and is subject to all applicable local, state, federal, and international laws.

11. Third Party Links and Websites.

Third-Party links to external websites provided through the Practice website are not controlled or sponsored by Practice. Client acknowledges and agrees that Practice is not responsible for the contents or availability of such third-party links or external websites. Use of such third-party links and external websites and the contents thereof is solely at Client's own risk.

12. Practice Names, Logos, and Materials.

The unauthorized use of Practice's name, logos, and materials are prohibited without the advance written consent of Practice.

13. Termination.

Either Party can cancel this Agreement at any time by giving 30 days' notice to the other Party. In such an instance, any unused portion of Client's membership fee will be refunded to Client's credit or debit card on a per diem basis. Notice to Practice shall be given by e-mail with electronic receipt requested to drlevy@apluspsychiatry.com.

(a) Cause.

This Agreement may be terminated by Practice if Practice determines, in its sole discretion, that 1) Client and Practice will not be able to work together; 2) it becomes clear that Practice cannot provide the care needed by Client; 3) Client's refusal to adhere to treatment recommendations endangers the health of Client or others; 4) Client has cancelled and/or missed an excessive amount of appointments; or 5) Client breaches any provision of this Agreement or any other agreement between the Parties. In such instances, Practice will refer Client to another practitioners with an appropriate scope of practice for the medical condition of Client and it shall be in Practice's sole discretion whether to refund some or all of any fees paid by Client.

(b) Client may be required, at Practice's sole discretion, to pay a reenrollment fee should Client wish to receive care from Practice at any point after this Agreement is terminated by either Party. The applicable reenrollment fees are set forth at: https://www.apluspsychiatry.com. In addition, Client and Practice shall execute another Agreement for Ongoing Telemedicine Psychiatric Care, or other agreement as deemed appropriate by Practice.

14. Indemnification.

Client releases all claims against, and also agree to indemnify Practice and its owners, directors, officers, employees, agents, representatives, heirs, successors, and assigns from and for all claims, rights, demands, suits, actions, causes of action, judgments, losses, damages, liabilities and expenses, including reasonable attorneys' fees, known or unknown, asserted or alleged, in connection with, arising out of, or related to a violation of this Agreement by Client, and Client's use of the Practice website, the Carrier Lines, and/or any external website.

15. Miscellaneous.

(a) Waiver of Breach.

Any waiver by either Party of a breach of any provision of this Agreement by the other Party shall not operate or be construed as a waiver of any subsequent breach by any Party.

(b) Assignment.

This Agreement and the rights and obligations of the parties under this Agreement shall not be assignable by Client without the written consent of Practice.

This Agreement and the performance hereunder and all suits and special proceedings hereunder be construed in accordance with and under and pursuant to the laws of Ohio without giving effect to theories of conflicts of laws. Any action or proceeding by either Party to enforce this Agreement shall be brought only in any state or federal court located in the State of Ohio, Cuyahoga County. The Parties irrevocably submit to the exclusive jurisdiction of such courts and waive the defense of inconvenient forum to the maintenance of any such action or proceeding in such venue.

(d) Severability.

All agreements and covenants contained herein are severable, and in the event, any of the same were be held to be invalid by any competent court, the Agreement shall be interpreted as if such invalid agreements or covenants were not contained herein.

(e) Entire Agreement.

This Agreement constitutes and embodies the entire understanding and agreement of the Parties with respect to the subject matter hereof and supersedes and replaces all prior understanding, agreements and negotiations between the Parties.

(f) Waiver and Modification.

Any waiver, alteration, or modification of any of the provisions of this Agreement shall be valid only if made in writing and signed by the Parties hereto. Each Party hereto, may waive any of its rights hereunder without effecting a waiver with respect to any subsequent occurrences or transactions hereof.

(g) Force Majeure.

Except for an obligation to pay fees, neither Party shall be liable for failure to perform any of its obligations under this Agreement during any period in which such Party cannot perform due to matters beyond their control, including, but not limited to, lightning strike, fire, flood, endemic, pandemic, or other natural disaster, war, embargo, or riot, provided that the Party so delayed immediately notifies the other Party of such delay in writing. The terms of this clause shall not exempt, but merely suspend, any Party from its duty to perform the obligations under this Agreement, until as soon as practicable after a force majeure condition ceases to exist.

(h) Parties in Interest.

Nothing in this Agreement, whether express or implied, is intended to confer any rights or remedies under or by reason of this Agreement on any persons other than the Parties and their respective successors and assigns, nor is anything in this Agreement intended to relieve or discharge the obligation or liability of any third persons to any party to this Agreement, nor shall any provision give any third person any right of subrogation or action over or against any party to this Agreement.

(i) Counterparts.

This Agreement may be executed simultaneously in two or more counterparts, each of which shall be deemed an original, but all of which taken together shall constitute one and the same instrument.

(j) Headings.

The headings contained herein are for the convenience of reference only and shall not in any manner affect the meaning or effect of anything herein contained.

IN WITNESS WHEREOF, the parties have executed this Agreement as of the day and year written below:

A PLUS PSYCHIATRY, LLC

Jess Levy, M.D.

Date: ________________________________

CLIENT

Print Name: ________________________________

Date: ________________________________

A+ Psychiatry

Hello@apluspsychiatry.com

“Have an A+ Day!”