# WHOOP, INC WHOOP Physician Services, PC Consent to Care

**WHOOP CONNECTED CARE CONSENT TO CARE**

This Consent to Care (“Consent”) sets forth the legally binding terms and conditions that apply to your receipt of medical care from WHOOP Physician Services, P.C. and its affiliated professional corporations (collectively, “Practice”) in connection with Practice’s participation in the Centers for Medicare & Medicaid Services Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model (the “ACCESS Program”). The technology-supported care program offered by Practice through the ACCESS Program is referred to herein as the “WHOOP Connected Care Program.” By checking the box and clicking submit, I confirm, I confirm that I have read and understand, and that I consent to, the terms set forth below.

**Consent to Treatment and Participation in the WHOOP Connected Care Program**

I consent to participate in the WHOOP Connected Care Program and receive technology-enabled medical care, including telehealth services (“Services”), from Practice and its personnel. I understand the following: (i) alignment to Practice and participation in the WHOOP Connected Care Program are voluntary; (ii) I may receive care from only one participant in the ACCESS Program (e.g., Practice) per ACCESS Program Clinical Track at a time; (iii) I may end my alignment with Practice (and, if desired, align with another participant in the ACCESS Program) at any time 90 days after I am aligned to Practice; and (iv) my claims data may be shared with Practice for health care operations, subject to privacy and security protections, including HIPAA.

If I am providing this consent on behalf of another person, I certify that I have the legal authority to provide this consent under applicable state law.

**Consent to Care Team Disclosures**

I authorize Practice to share care updates and related medical information with my primary care physician or referring clinician for treatment purposes and as otherwise required by the ACCESS Program, and to share such information with other health care providers for treatment purposes. I also acknowledge and agree that to facilitate my participation in the WHOOP Connected Care Program, Practice will ask me for information about my primary care physician or other regular health care provider.

If at any time I wish to modify my data-sharing preferences, I may call 1-800-Medicare to do so. However, even if I decline data-sharing, CMS may still engage in limited sharing of my data for care coordination and quality improvement activities and population-based activities relating to improving health or reducing health care costs.

**Limitations of Technology-Enabled Care**

I acknowledge and agree that there are limitations to technology-enabled care, and that Practice may not be capable of solving my medical problems. Technology-enabled care is not a substitute for in-person medical care. Practice cannot guarantee the quality of any network connectivity. I am responsible for following up with my own primary care physician or other regular health care provider as recommended or instructed by Practice in connection with the Services. If I experience a medical emergency, I should call 911 or seek emergency medical care as soon as possible. If I have a medical question or need, I should consult my primary care physician or other regular health care provider.

**Assignment of Benefits**

I confirm that I have requested Services from Practice, and I hereby assign to Practice all applicable health insurance benefits and payments (each such payment or benefit, a “Benefit”) and all rights to which I am entitled (or which I have actually received) from Medicare in connection with the Services. I certify that the information I provided in applying for Medicare is correct. I understand that my ability to receive Services from Practice is contingent upon my enrollment in Medicare. I hereby appoint Practice as my authorized representative (“Authorized Representative”) with the power to: (i) file and process medical claims with Medicare or its contractors; (ii) file appeals and grievances with Medicare or its contractors; and (iii) institute and pursue on my behalf any claim, right or cause of action, including any necessary litigation and/or complaints against Medicare or its contractors (even to name me as a plaintiff in such action).

This assignment of benefits supersedes any prior or contemporaneous understandings or agreements with Practice with respect to the subject matter hereof.

**Patient Receipt of Checks**

I direct Medicare and its contractors to issue payment checks directly to Practice. In the event that I receive direct payment of any amounts due for Services rendered by Practice and an Explanation of Benefits (“EOB”) related to such Services, I agree to forward promptly to Practice any checks made payable to me for Services rendered, endorsed to the order of Practice, and any related EOB. I agree to (i) notify Practice upon receipt of any such check, (ii) endorse the check “Pay to the Order of WHOOP Physician Services, P.C.”, (iii) immediately mail such check and EOB to Practice, and (iv) keep copies of the check and EOB for my records. I acknowledge that in the event I fail to forward the check and EOB to Practice within thirty (30) days of receipt, I may be held responsible for the total charge for the Services.

**Financial Responsibility**

I acknowledge and agree that the Services will be provided to me free of charge, and that any deductibles, co-payments, or co-insurance related to the Services will be waived by Practice in accordance with the terms of the ACCESS Program and 42 C.F.R. § 1001.952(ii)(2). The WHOOP band, accessories, and software (including the “Blood Pressure Insights” feature) (collectively, the “WHOOP Band”) and a blood pressure cuff will be provided to me at no cost, solely to facilitate my access to the Services. I acknowledge and agree that I cannot obtain Services from Practice unless I receive the WHOOP Band and blood pressure cuff because the technology-enabled Services rely on my use of these products. I agree to return the WHOOP Band and blood pressure cuff to Practice upon request, including if I withdraw from the WHOOP Connected Care Program or Practice terminates my participation.

Notwithstanding the foregoing, I acknowledge and agree that I will be responsible for any fees or charges related to any services, products, or features offered by WHOOP, Inc., including WHOOP Advanced Labs, Clinician in the Loop, and any upgrades to the WHOOP Band.

**Notice of Privacy Practices**

I acknowledge that I have read and agree to Practice’s HIPAA Notice of Privacy Practices, available [here](/content/us/en/privacy-practices/index.html). I consent to Practice’s use and disclosure of my protected health information in accordance with its HIPAA Notice of Privacy Practices and applicable law, including for treatment, payment, and health care operations purposes.

**Provision of Services**

When I receive Services from Practice, the health care provider that is directly providing Services to me will depend upon the state in which I am located. Services will be offered in all states in which Practice is authorized to provide Services in accordance with applicable laws and regulations.

**Withdrawal and Termination**

My participation in the WHOOP Connected Care Program is voluntary, and I may withdraw from the WHOOP Connected Care Program at any time by notifying Practice in writing. Practice may terminate my participation in the WHOOP Connected Care Program at any time, with or without cause, upon written notice to me. Termination of my participation will not affect any rights or obligations that accrued prior to termination, including my obligation to return the WHOOP Band and blood pressure cuff.

**Governing Law**

This Consent shall be governed by and construed in accordance with the laws of the Commonwealth of Massachusetts, without regard to its conflict of laws principles.

**Entire Agreement; Amendment**

This Consent, together with Practice’s HIPAA Notice of Privacy Practices, constitutes the entire agreement between me and Practice with respect to the subject matter hereof and supersedes all prior or contemporaneous understandings or agreements. Practice may amend this Consent from time to time by providing notice to me of such amendment. My continued receipt of Services after such notice constitutes my acceptance of the amended Consent.