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Patient Application

Applying to become an IMA member is simple process. Once your application is reviewed and approved, will be able to access services at a reduced rate. Please complete the form below to get started.

Step 1: Complete the IMA Membership Application.
The information you provide for this application will be used determine eligibility for reduced fees services. Your information will be viewable to potential healthcare providers, site administrators, and yourself.
Email*
Name*
First Last
Home Address
Please provide your home mailing address.

Street Address Address Line 2 City State ZIP Code
Phone*
Date of Birth*
Gender*
- Female
- Male
- Intersex
- Neutral
- Unknown
Total Number in Household*
Total Number Employed
Total Household Income*
Highest Grade Level Completed*
- No high school
- High school
- Some college
- Graduated college
- Some professional or graduate school
- Obtained graduate degree
Name of Primary Care Physician
Date of Last Visit with Primary Care Physician
List the 3 medical conditions that are of most concern for you.
How did you hear about IMA?
- Friend
- Primary Care Physician
- Web Search
- Other
Briefly describe how you heard about IMA
What modality are you most interested in?
Step 2: Upload Proof of Household Income.
Anyone can register and search for providers in their area. However, in order to qualify for discounted services, you must make less than the maximum amounts listed below. Please upload supporting documentation, such as official tax forms (1040, W2, or 1099), 2 recent pay stubs, or another form of income verification.
For a family of 1, you must make $22,980 or less.
For a family of 2, you must make $31,020 or less.
For a family of 3, you must make $39,060 or less.
For a family of 4, you must make $47,100 or less.
For a family of 5, you must make $55,140 or less.
Upload file here.
Maximum file size is 2MB. Allowed file extensions: jpg, gif, png, pdf.
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Step 3: Accept Agreement.
Please review the CLIENT AGREEMENT above (by scrolling to the bottom).
INTEGRATIVE MEDICINE ACCESS CLIENT AGREEMENT

This Integrative Medicine Access Client Agreement (the "Agreement") is made and entered into as of (the "Effective Date"), by and between Integrative Medicine Access ("IMA"), a California non-profit corporation, and , an individual ("Client"). IMA and Client are sometimes referred to in this Agreement as a "Party" or, collectively, as the "Parties".

RECITALS

A. IMA is the owner and operator of that certain website domain with the uniform resource locator http://www.integrativemedicineaccess.org (the “Website”). The Website facilitates the connection of certain qualified and registered patients with participating health care practitioners (the “Participating Practitioners”) for the scheduling of medical appointments (the “Services”); and

B. Client is an individual who meets certain financial conditions, and IMA desires to include Client on its list of qualified and registered patients (“Approved Client List”), and Client desires the same in order to obtain access to Participating Practitioners.

NOW, THEREFORE, for and in consideration of the recitals above and the mutual covenants and conditions set forth herein below, IMA and Client agree as follows:

1. Client’s Responsibilities.

1.1. Client’s Representations and Warranties. Client hereby warrants and represents that:

1.1.1. Client’s annual income is below Two Hundred Percent (200%) of the Federal Poverty Income Guideline (the “Eligibility Requirements”) as adjusted for the size of Client’s family (“FPIG”). The FPIG is revised each year and published by the United States Department of Health and Human Services (“HHS”); and

1.1.2. Client has provided, to the best of Client’s ability and belief, true and accurate information for all written application materials (the “Application Materials”) Client submitted to IMA for inclusion on the Approved Client List. Application Materials may change from time to time, the most current version of which can be found at the following link on the Website: https://www.integrativemedicineaccess.org/patient-application

1.2. Notification Regarding Change in Eligibility. Client shall immediately notify IMA in writing or through the following link on the Website in the event of any change in Client’s eligibility requirements as set forth in Section 1.1 of this Agreement.

1.3. Protected Health Information. By entering into this Agreement, Client agrees as follows:

1.3.1. Client represents and warrants that Client shall not post, transmit, disseminate or send in any way or form whatsoever information relating to Client’s protected health information (“PHI”) as defined by the Health Insurance Portability and Accountability Act of 1996, as amended from time to time and including its implementing regulations (collectively “HIPAA”). Client is informed, understands and agrees that IMA does not make any representations about the security of its Website, and in particular of the security of any PHI that may exist on the Website, with or without IMA’s knowledge or consent.

1.3.2. Notwithstanding Subsection 1.3.1., in the event Client provides IMA or any Participating Practitioner with certain PHI, Client agrees to execute IMA’s written release relating to protected health information (“PHI”) as defined by the Health Insurance Portability and Accountability Act of 1996, as amended from time to time and including its implementing regulations (collectively “HIPAA”), a copy of which is attached hereto as Exhibit “A” (the “PHI Release”). Pursuant to the PHI Release, IMA and certain Participating Practitioners’ may securely maintain and share information regarding Client, and in particular information relating to Client’s health, treatment and PHI.

1.4. Financial Matters.

1.4.1. Uninsured Clients. If Client is Uninsured (as defined below), Client agrees to pay each Participating Practitioner who provides Services to Client a fee in the amount of Twenty Dollars ($20.00) for the initial appointment (“Initial Fee”), and Ten Dollars ($10.00) for each appointment thereafter (“Subsequent Fee”). Except for the monetary amounts listed in this Subsection 1.4.1, Uninsured Clients shall have no further monetary obligation for Client’s office visits at a Participating Provider. For purposes of this Agreement “Uninsured” refers to a Client who has no agreement with any third party payer, directly or indirectly, for payment in whole or in part of Client’s health care expenses and medical treatment, as evidenced by a health insurance policy, coverage through a federal or state program, or coverage that may result from certain third party liability, directly or indirectly, through tort or contract.

1.4.2. Insured Clients. If Client does not meet the definition of Uninsured (“Insured Clients”), Client agrees to provide each Participating Practitioner who provides Services to Client with all information necessary for the Participating Practitioner to submit billing information, and to the extent permitted by law and the basis by which Client is an Insured Client, so that Participating Practitioner can bill and collect for the Services Participating Practitioner provides to Client.

1.4.3. Appointment Cancellation Policy. If a Client fails to provide notice of at least one (1) business day before cancelling an appointment with a Participating Practitioner, Client shall pay Participating Practitioner either the Initial Fee or Subsequent Fee, as applicable. If the Client fails to provide timely notice of cancellation for more than one appointment, the Participating Practitioner may take necessary steps to terminate its professional relationship with Client, so long as such steps are taken in compliance with all applicable laws and regulations as required by federal and state law.

1.4.4. Acknowledgment. While IMA strives to ensure that only qualified and properly credentialed Participating Practitioners qualify as Participating Practitioners, IMA makes no representation or warranty that the information it may receive from any Participating Practitioner is always complete and accurate, and IMA shall have no responsibility or liability to Client, including liability for monetary damages, in the event information about a Participating Practitioner is not accurate.

2. IMA’s Responsibilities.

2.1. Maintenance of Website. IMA agrees to maintain in good faith the Website, and to maintain Client’s listing on the Approved Client List as long as Client maintains eligibility. Notwithstanding the above, IMA shall not be responsible and have no liability for information about a Client on the Website that is not accurate and complete.

2.2. Acceptance by Participating Practitioners. Through the IMA Website Clients obtain information about Participating Practitioners. Notwithstanding the above, IMA makes no guarantee or representation that any Participating Practitioner will agree to accept Client as a patient.

2.3. Compliance with Applicable Laws. IMA shall comply with all applicable laws, statutes, regulations, ordinances, and other legal authorities relating to this Agreement and under which IMA may be bound (“Applicable Law”).

3. Term and Termination.

3.1. Term. Subject to rights of Client and IMA to terminate this Agreement as set forth below, this Agreement shall commence on the Effective Date and remain in full force and effect for a period of one (1) year. This Agreement shall automatically be renewed for additional term(s) of one (1) year until terminated as set forth in this Article Three.

3.2. Immediate Termination by IMA. IMA reserves the right to terminate this Agreement in its sole and absolute discretion at any time and without notice to Client. Any termination pursuant to this Section 3.2 shall not modify or otherwise relieve Client or any Participating Practitioner of their respective legal obligations and duties to the other.

3.3. Termination by Client. Client may terminate this Agreement without cause on any time by written notice or submission of intent to terminate by contacting IMA.

4. Relationship of the Parties.

4.1. No Practitioner-Patient Relationship. The Parties expressly agree, as a material inducement to entering into this Agreement, that this Agreement and/or its performance do not and will not create a practitioner-patient relationship. Client further agrees that solely by inclusion on the Approved Client List, Client will not communicate emergency health care information, including PHI, to any Practitioner or to IMA at any time. Any information that may be exchanged between Client and a Practitioner shall be done pursuant to a separate agreement (written, oral and/or implied) between Client and a Practitioner, and it shall not modify the provisions set forth in this Section 4.1. If a court of competent jurisdiction rules that this Agreement and/or its performance does create a practitioner-patient relationship, Client hereby waives any claims, damages, or causes of action it may have against IMA related to such practitioner-patient relationship.

Client Initials:

Client further agrees that in the event of any medical emergency, Client will call 9-1-1 immediately.

Client Initials:

4.2. Survival. The provisions of Section 4.1 shall survive expiration or other termination of this Agreement, regardless of the cause of such termination.

5. General Terms.

5.1. Governing Law; Venue; Attorney Fees. This Agreement has been made and executed in, and shall be construed and enforced according to the laws of the State of California, without reference to its conflict of law principles. Venue shall be in the courts of the County of Los Angeles. In the event of a dispute, the Parties shall submit such dispute to mandatory arbitration conducted by Judicial Arbitration and Mediation Services, Inc. (“JAMS”). Each Party shall pay its own expenses in connection with the arbitration, although an arbitrator may award the prevailing party reasonable costs and attorney’s fees.

5.2. Assignment. Any attempt by Client to assign this Agreement shall result in immediate termination of this Agreement by IMA. IMA may freely assign this Agreement at any time and without authorization to any subsidiary or any entity which has, or subsequently obtains, control or a controlling interest in IMA or an IMA subsidiary.

5.3. Provisions Held Invalid. If any one or more of the provisions contained in this Agreement shall be held to be invalid, illegal or unenforceable for any reason or in any respect, such invalidity, illegality or unenforceability shall not affect any other provision hereof, and this Agreement shall be construed as if such provision had never been contained herein.

5.4. Entire Agreement. This Agreement is the entire understanding and agreement of the Parties regarding its subject matter, and supersedes any prior oral or written agreements, representations, understandings or discussions between the Parties. No other understanding between the Parties shall be binding on them unless set forth in writing, signed and attached to this Agreement.

IN WITNESS WHEREOF, the parties have executed this Agreement, effective as of the date first above written.

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Please review the CLIENT AGREEMENT above (by scrolling to the bottom) and the TERMS OF USE below before submitting your application. By clicking SUBMIT, you agree to abide by the CLIENT AGREEMENT and the TERMS OF USE and verify that the information you have provided is true and correct to the best of your knowledge.
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