Telehealth Credit Card Authorization & Service Agreement
I, the undersigned, hereby authorize RHVB LLC (“Relive Health”) to charge the payment method on file for telehealth services, medications, and related products as described in this agreement. By signing below, I confirm that I have read, understood, and agree to all terms and conditions outlined herein.
1. Payment Authorization
I authorize Relive Health to charge the credit or debit card on file for all telehealth services, prescribed medications, and associated products. Charges will occur automatically according to the payment schedule established at the time of enrollment. I understand it is my responsibility to maintain a valid payment method on file at all times.
I understand that my payment amount may vary relative to the specific treatment protocol prescribed by my provider. Any changes to my payment amount will be communicated in advance. I agree this authorization remains valid for all future charges associated with my care unless cancelled in accordance with the cancellation policy below.
- I authorize Relive Health to charge the payment method on file for all telehealth services, medications, and products associated with my care.
- I understand that my payment amount may change based on my prescribed treatment plan and I will be notified in advance of any changes.
- I understand that my payment information will be securely stored and kept on file for future transactions. 2. Minimum Commitment Period By entering into this agreement, I commit to a minimum of six (6) months of telehealth services with Relive Health. I agree to fulfill all scheduled payments during this period, regardless of changes in personal schedule, travel, or other individual circumstances. Early termination prior to the completion of the six-month minimum is not permitted without payment of the remaining balance in full. Following the minimum commitment period, services will continue on a month-to-month basis until a written cancellation request is submitted in accordance with the cancellation policy outlined in Section 5.
- I understand and agree to a minimum commitment period of six (6) months and agree to fulfill all scheduled payments during this time.
- I understand that early termination prior to completing the six-month minimum requires payment of the remaining balance in full.
- I understand that after the minimum commitment period, my payment method will continue to be charged on the same schedule until I submit a written cancellation request. 3. Non-Refundable Products & Services
I acknowledge and agree that all payments for telehealth services, prescribed medications, and associated products are final and non-refundable. Once a product has been dispensed, prepared, or shipped, it cannot be returned and no refund will be issued under any circumstance.
This policy applies to all medications, compounds, supplements, kits, and any other products or services associated with my Relive Health telehealth program. I understand that this non- refundable policy exists due to the individualized and perishable nature of compounded and prescribed medications.
• I understand that all payments are final and non-refundable, and that no refunds will be issued once a product has been dispensed, prepared, or shipped.
4. Bloodwork Compliance Requirement
I understand that Relive Health is a data-driven telehealth program. Up-to-date laboratory bloodwork must remain on file at all times in order to continue receiving medication shipments, treatment refills, or any ongoing telehealth services.
Failure to complete required follow-up bloodwork within the timeframe established by my provider may result in a hold on shipments and services until compliant labs are received and reviewed. Standard bloodwork intervals are as follows, though my provider may require more frequent monitoring based on my individual treatment plan: Hormone Replacement Therapy (HRT), 6 weeks post-initiation then every 6 months; Medical Weight Loss and Peptide Therapy, every 6 months or per provider discretion; all clients, an annual Good Faith Exam (GFE) is required.
- I understand that up-to-date bloodwork must remain on file in order to continue receiving medication shipments and telehealth services.
- I understand that failure to complete required follow-up labs within the timeframe established by my provider may result in a hold on shipments and services. 5. Cancellation Policy Cancellation requests will not be accepted by phone or email. A written cancellation request must be submitted and acknowledged by Relive Health. Cancellation requests must be received a minimum of thirty (30) days prior to the next scheduled payment date. Cancellation is only available after the six (6) month minimum commitment period has been fulfilled. I agree that this authorization will remain in effect until a valid cancellation request has been received and confirmed in writing by Relive Health.
- I understand that cancellations require a written request submitted at least thirty (30) days prior to the next scheduled payment and are only permitted after the six-month minimum commitment period.
- I agree that this authorization remains in effect until Relive Health confirms receipt of a valid written cancellation request. 6. Biobox At-Home Collection – Compliance Requirements If I am completing my bloodwork using the Access Biobox at-home self-collection kit, I understand and agree to the following non-negotiable collection and shipping requirements. Collection must occur Monday through Thursday only; Friday, Saturday, and Sunday
collections are not permitted. The sample must be shipped back to Access Labs on the same day as collection using the prepaid return label included in the kit, and the return package must be dropped off at a FedEx location that same day. Packages dropped off on Friday will not be received or processed until the following Monday, adding two to three days to turnaround. Results are typically returned within 24 to 48 hours of Access Labs receiving the sample.
- I understand that Biobox collection must occur Monday through Thursday only, and that my sample must be shipped back to Access Labs on the same day as collection.
- I understand that collecting or shipping my sample on a Friday, Saturday, or Sunday may result in sample degradation, delayed results, and a postponed provider visit.
- I understand that it is my responsibility to follow the collection and shipping instructions provided with my kit and confirmed by my Client Advocate. 7. Provider Change & Relocation Policy I understand that my telehealth services are provided by a licensed medical provider (NP, PA, or MD) authorized to prescribe in my state of residence. Relive Health reserves the right to assign or reassign a licensed provider to my care at any time, and a change in assigned provider does not constitute grounds for cancellation or refund. If I move to a new state, I understand that I must notify Relive Health promptly, and that continued services are contingent upon Relive Health having a licensed provider authorized to prescribe in my new state of residence. Relocation does not exempt me from the minimum commitment period or outstanding payment obligations.
- I understand that Relive Health may assign or reassign a licensed provider to my care at any time and that a provider change does not constitute grounds for cancellation or refund.
- I understand that if I relocate to a new state, I must notify Relive Health promptly, and that continued services are contingent upon provider licensure availability in my new state.
- I understand that relocation does not exempt me from my minimum commitment period or any outstanding payment obligations. 8. Dispute & Chargeback Waiver By signing this agreement and authorizing Relive Health to charge my payment method, I acknowledge that all charges made in accordance with this agreement are valid, authorized, and non-disputable, provided that services and/or products have been rendered or shipped as agreed. I agree that I will not initiate a chargeback, dispute, or reversal with my bank or card issuer for any charge that is consistent with the terms of this agreement. I understand that initiating an unauthorized chargeback constitutes a breach of this agreement, and Relive Health reserves the right to immediately suspend services and pursue recovery of the disputed amount.
- I acknowledge that all charges made in accordance with this agreement are valid and authorized, and I agree not to initiate a chargeback or dispute for any charge consistent with these terms.
- I understand that initiating an unauthorized chargeback constitutes a breach of this agreement and may result in immediate suspension of services and pursuit of recovery.
• I agree to contact Relive Health directly to resolve any billing concerns before contacting my bank or card issuer.
9. General Agreement
I agree that this contract will be upheld even if my payment amount or payment date changes, relative to what is being purchased or prescribed. I acknowledge that Relive Health reserves the right to pause or discontinue services if payment obligations are not met or if required compliance items (including bloodwork) are not maintained.
By signing below, I confirm that I have read and fully understand this agreement, including the six-month minimum commitment, the non-refundable product policy, the bloodwork compliance requirement, the Biobox collection requirements, the provider and location change policy, the dispute and chargeback waiver, and the cancellation policy.
• I have read, understood, and agree to all terms and conditions of this Credit Card Authorization and Service Agreement.