Suneha Sundaram, MD PLLC, doing business as Triangle Longevity Clinic · Cash-Pay Medical Services: Longevity & Preventive Medicine
THIS AGREEMENT IS NOT HEALTH INSURANCE. TRIANGLE LONGEVITY CLINIC DOES NOT ACCEPT MEDICARE OR MEDICAID. This Agreement does not replace major medical, hospitalization, or emergency coverage.
This Direct-Pay Membership Agreement (“Agreement”) is entered into as of the Effective Date written below by and between Suneha Sundaram, MD PLLC, a North Carolina professional limited liability company operating as “Triangle Longevity Clinic” (the “Clinic,” “we,” “us,” or “our”), and the patient named below (“Patient,” “you,” or “your”). The Clinic and Patient may each be referred to as a “Party” and together as the “Parties.”
1.1 This Agreement establishes a direct-pay membership relationship between Patient and Clinic. In exchange for the membership fees described in Schedule A (attached and incorporated by reference), Clinic will provide the services described in this Agreement directly to Patient, without billing or involving any health insurance plan, Medicare, Medicaid, or other third-party payor.
1.2 This Agreement is not health insurance and does not replace major medical or catastrophic health insurance. Patient is strongly encouraged to maintain separate health insurance coverage for services outside the scope of this Agreement, including hospitalization, specialist care, and emergency care.
1.3 Clinic does not file claims with, seek reimbursement from, or accept payment from any insurance company, health plan, or government payor on Patient’s behalf under this Agreement.
1.4 Medicare Not Accepted. Clinic does not accept Medicare (including Medicare Advantage plans) and will not bill Medicare for any item or service. If Patient is enrolled in Medicare Part B, Clinic can provide services only under Clinic’s separate Medicare Private Contract, which must be signed before any services are provided. Neither Patient nor Clinic will submit a claim to Medicare for those services, and Medicare will not pay for them.
1.5 Medicaid Not Accepted. Clinic does not accept North Carolina Medicaid (including NC Medicaid Managed Care plans) and will not bill Medicaid for any item or service. If Patient is a Medicaid beneficiary, Patient must sign Clinic’s separate Medicaid Non-Acceptance Notice before services are provided, confirming that Patient understands Medicaid will not be billed and Patient will be responsible for all charges.
1.6 Good Faith Estimate. Patient has the right to receive a Good Faith Estimate of the expected charges for scheduled items and services, as described in Clinic’s Good Faith Estimate Notice. Clinic will provide a written Good Faith Estimate before services as required by the federal No Surprises Act.
1.7 Eligibility. Membership is available only to adults age 18 or older. Telehealth services are provided only while Patient is physically located in North Carolina or in another state where Clinic’s physician is licensed and legally permitted to provide care.
AUTOMATIC RENEWAL: THIS MEMBERSHIP RENEWS AUTOMATICALLY AT THE END OF EACH TERM UNLESS YOU CANCEL. You may cancel at any time as described in Sections 2 and 12.
2.1 Initial Term. This Agreement begins on the Effective Date and continues for the initial membership period selected by Patient and identified in Schedule A.
2.2 Automatic Renewal. This Agreement will automatically renew for successive terms of the same length as the then-expiring term, at the then-current membership fee, unless either Party provides written notice of non-renewal at least thirty (30) days before the end of the then-current term.
2.3 Renewal Reminder. Before each automatic renewal, Clinic will send Patient written notice by email or mail, no fewer than fifteen (15) and no more than forty-five (45) days before the renewal date, stating the renewal date, the renewal fee, and how to cancel. Any change to the terms that will apply in the renewal term will be stated clearly and conspicuously in at least 12-point bold type.
2.4 Fee Changes on Renewal. Clinic may change membership pricing for a renewal term only by providing Patient written notice at least forty-five (45) days before the renewal date. If Patient does not wish to renew at the new fee, Patient may cancel without penalty at any time before the renewal date, even if the thirty (30) day non-renewal deadline in Section 2.2 has passed.
2.5 How to Cancel. Patient may cancel renewal or terminate this Agreement by email to admin@trianglelongevityclinic.com, by mail to the Clinic address shown on this Agreement, or by any other method described in Section 18.
3.1 Patient agrees to pay the membership fees set forth in Schedule A. Fees are due as described in Schedule A and are charged directly to Patient using the payment method Patient provides.
3.2 Except for the baseline testing panel included in the Initial Consultation, Testing & Assessment fee described in Schedule A, membership fees do not include, unless separately agreed in writing: other outside laboratory or imaging fees; compounded or brand-name medications; injectable peptides or hormones themselves (as opposed to their evaluation, prescribing, and monitoring); durable medical equipment; specialist consultations; hospital or emergency services; or any services outside the scope described in this Agreement. Clinic will tell Patient the expected cost of any additional item or service before it is ordered.
4.1 Services provided under the membership fee are individualized to Patient based on Clinic’s clinical assessment and may include, as clinically appropriate: hormone therapy (including evaluation, prescribing, and monitoring); peptide therapy; nutritional and therapeutic supplement recommendations; diagnostic and biomarker testing panels; exercise tolerance and fitness-capacity testing; and related consultation, assessment, and follow-up. The specific services provided to Patient are determined individually and may change over time based on Patient’s results, goals, and clinical presentation.
4.2 Clinic retains full clinical discretion to determine the services, testing, and treatment appropriate for Patient. Nothing in this Agreement obligates Clinic to provide any specific test, treatment, medication, or referral that Clinic’s treating physician does not consider medically appropriate for Patient at a given time.
4.3 Physician’s Independent Professional Judgment. All recommendations, assessments, and treatment plans provided under this Agreement reflect the treating physician’s independent professional judgment, exercised in good faith and to the best of the physician’s knowledge, training, and ability, based on the information available at the time of the recommendation. Recommendations may reasonably change as new information becomes available (including test results, Patient’s response to treatment, or updated medical literature), and may reasonably differ from what another qualified provider would recommend.
4.4 Individualized Care and Published Guidelines. Some recommendations, including which tests are ordered, how often, and the target ranges used, may differ from screening or treatment guidelines issued by organizations such as the U.S. Preventive Services Task Force or medical specialty societies. Those guidelines are designed for broad populations; Patient’s plan is tailored to Patient, and in some areas of longevity and preventive medicine the scientific evidence is still evolving. When a recommendation differs from a published guideline, or involves an off-label or non-FDA-approved use, the physician will explain the reason, the potential benefits, risks, and uncertainties, and the reasonable alternatives, including following the standard guideline, so that Patient and physician can decide together. Following any recommendation is Patient’s choice.
5.1 General Acknowledgment. Patient acknowledges that the services described in Section 4 involve independent risks, that Clinic has encouraged Patient to ask questions about any service before receiving it, and that Patient’s consent to each category of service below is voluntary and may be withdrawn at any time by notifying Clinic, without affecting Patient’s membership. Additional, treatment-specific consent forms may be required before certain treatments begin.
5.2 Patient’s Right to Decide. Patient has the right, and the corresponding responsibility, to decide whether to begin, continue, or decline any specific treatment, test, or service Clinic recommends. Declining any single recommended service does not affect Patient’s membership, and Clinic will continue to provide the other services Patient elects to receive under this Agreement.
Patient understands that hormone therapy (including but not limited to testosterone, estrogen, progesterone, or thyroid therapy) carries known risks that may include, among others, cardiovascular effects, changes in mood, changes in fertility, effects on existing or undetected hormone-sensitive conditions, polycythemia, and other effects specific to the hormone(s) prescribed. Response to hormone therapy varies significantly by individual, and required dosing, monitoring, and duration cannot be guaranteed in advance. Clinic does not prescribe human growth hormone for anti-aging, longevity, or performance purposes.
Patient understands that many peptides used in longevity medicine are not FDA-approved for the specific use recommended, may be compounded rather than manufactured under an FDA-approved application, and have less long-term safety data available than conventional FDA-approved medications. Clinic will prescribe only preparations that may lawfully be compounded and dispensed by a licensed pharmacy. Patient’s consent to peptide therapy includes consent to this uncertainty.
Patient understands that dietary supplements recommended by Clinic are not evaluated by the FDA for safety or effectiveness before sale, and may interact with medications or existing conditions. Patient is responsible for disclosing all supplements, medications, and substances Patient is taking, from any source, as described in Section 8.
Laboratory tests ordered by Clinic are performed by licensed clinical laboratories, and Clinic’s physician will review the results, discuss them with Patient, and recommend appropriate follow-up. Some longevity-related measures, such as composite “biological age” scores or certain specialty biomarkers, are estimates whose clinical meaning is still being studied; Clinic will explain their limitations and will not use them as the sole basis for a diagnosis.
Patient understands that broader testing than is typical for routine screening can produce unexpected or borderline results (“incidental findings”) and false-positive results. These may lead to additional testing, imaging, or specialist referral, with additional cost not included in membership fees, and occasionally to anxiety or procedures that in hindsight were not needed. Clinic will discuss the significance of any incidental finding and the reasonable options for follow-up, including watchful waiting where appropriate.
Exercise and fitness-capacity testing involves physical exertion and carries cardiovascular and musculoskeletal risk, including, rarely, serious cardiac events. Testing is performed only in person, after pre-test screening, with an emergency plan in place; Clinic may require additional evaluation or clearance before testing. Patient agrees to disclose all known cardiac, pulmonary, orthopedic, and other relevant conditions beforehand and to stop testing and alert staff immediately if Patient experiences chest pain, severe shortness of breath, dizziness, or other concerning symptoms.
5.3 By initialing below, Patient confirms that Patient has read and understands this Section 5, has had the opportunity to ask questions about each category of service Patient elects to receive, and voluntarily accepts the risks described above to the extent Patient elects to receive the corresponding service.
6.1 Some medications, peptides, or protocols recommended by Clinic may be prescribed “off-label” (for a use, dose, or population not specifically approved by the FDA) or may involve compounded preparations not individually approved by the FDA. Off-label use is a lawful and common practice in medicine, but it means the specific use has not undergone the FDA’s own review for that purpose.
6.2 As part of the informed-consent discussion for the relevant service, Clinic will disclose to Patient when a recommended treatment is off-label or compounded, together with its reasonably known risks, benefits, and alternatives, so that Patient can make an informed decision whether to proceed.
7.1 The practice of medicine, including longevity and preventive medicine, is not an exact science. Clinic makes no promise, warranty, or guarantee, express or implied, regarding the outcome, results, or effectiveness of any consultation, assessment, test, treatment plan, or other service provided under this Agreement.
7.2 Clinic does not guarantee any specific change in lifespan, healthspan, biomarker values, body composition, performance metric, or “biological age” score, and no statement by any Clinic provider or staff member shall be construed as such a guarantee. Individual results vary based on many factors, including genetics, behavior, and adherence to recommendations.
8.1 Patient agrees to provide complete, accurate, and truthful information regarding Patient’s medical history, current symptoms, medications, supplements, allergies, prior diagnoses, substance use, family history, and any other information reasonably requested by Clinic to provide safe and appropriate care.
8.2 To the extent permitted by applicable law, Clinic and its providers are not responsible for adverse effects, complications, interactions, or other outcomes that result from medical conditions, medications, supplements, treatments, or other material health information that Patient did not disclose or did not accurately report. Nothing in this Section waives rights or protections that cannot lawfully be waived or limits Clinic’s professional obligations under applicable law.
8.3 Patient agrees to promptly notify Clinic of any changes to Patient’s health status, medications, supplements, or other information previously provided that could reasonably affect Patient’s care.
9.1 Clinic maintains policies and procedures designed to comply with the Health Insurance Portability and Accountability Act of 1996, as amended, and its implementing regulations (“HIPAA”), and with applicable North Carolina privacy law.
9.2 Clinic has provided Patient with its Notice of Privacy Practices. By signing this Agreement, Patient acknowledges receipt of that Notice, or that Patient has been given the opportunity to review it.
9.3 Clinic will not use or disclose Patient’s protected health information except as permitted or required by HIPAA, as authorized in writing by Patient, or as otherwise permitted by law.
10.1 Many visits, follow-ups, and monitoring under this Agreement are conducted by secure telehealth (video or, when clinically and legally appropriate, audio). Patient consents to telehealth and understands its limitations, including the absence of a hands-on physical examination. Clinic may require an in-person visit, outside testing, or other evaluation when telehealth is not clinically sufficient. Additional telehealth terms appear in Clinic’s Terms of Medical Services.
11.1 Patient consents to receive appointment reminders, lab-result notifications, renewal reminders, and administrative communications from Clinic by email and/or text message at the contact information Patient provides. Message and data rates may apply. Patient may withdraw this consent at any time by notifying Clinic, without affecting Patient’s membership, though Clinic may still need to reach Patient by phone or mail for essential care-related matters. Marketing messages are sent only with Patient’s separate consent.
12.1 Termination by Patient. Patient may terminate this Agreement and Patient’s membership at any time, for any reason, by written notice to Clinic in accordance with Section 18.
12.2 Termination by Clinic. Clinic may terminate or limit the physician-patient relationship and this Agreement when reasonably appropriate and for any lawful reason, including nonpayment, repeated failure to comply with Clinic policies, abusive or threatening behavior, falsification or material omission of information, misuse of prescriptions or medical services, or other circumstances that materially interfere with Clinic’s ability to provide safe and appropriate care. Except where immediate termination is warranted for safety, Clinic will give reasonable advance written notice (ordinarily thirty (30) days), remain available for urgent needs during the notice period, help Patient transition care, and make Patient’s records available in accordance with applicable law. Clinic will not terminate the relationship in a manner that constitutes patient abandonment.
12.3 Effect of Termination. Upon termination, Patient’s right to receive services under this Agreement ends as of the effective date of termination, subject to the refund provisions of Section 13. Termination does not relieve Patient of the obligation to pay for services already rendered.
13.1 Cancellation by Patient. If Patient cancels before the end of the then-current membership term, Clinic will refund the prorated fee attributable to each full calendar month remaining in the term as of the effective date of cancellation. Any partial month in which cancellation becomes effective is treated as used and is not refundable.
13.2 Example (illustration only): if Patient is enrolled in the 12-month membership and cancels with five (5) full calendar months remaining, Patient will receive a refund equal to five-twelfths (5/12) of the 12-month membership fee, less any amounts otherwise due to Clinic.
13.3 Termination by Clinic or Provider Unavailability. If Clinic terminates this Agreement for any reason other than Patient’s breach, or if Clinic is unable to provide membership services because the treating physician becomes unavailable (Section 21), Clinic will refund the prorated fee for the remainder of the term, calculated on a daily basis.
13.4 Approved refunds will be issued to the original payment method within thirty (30) days of the effective date of cancellation or termination, unless otherwise required by applicable law.
14.1 Patient is responsible for all fees under this Agreement and any separately billed services Patient elects to receive. Amounts not paid when due may accrue a late fee of the lesser of 1.5% per month or the maximum rate allowed by North Carolina law. If an account is referred to collections or requires legal action to collect, Patient agrees to reimburse Clinic’s reasonable collection costs and attorneys’ fees to the extent permitted by North Carolina law.
14.2 If a payment is returned or declined, Patient agrees to reimburse Clinic for the actual fee charged to Clinic by its bank or payment processor, not to exceed the amount permitted by North Carolina law. Clinic does not add any additional service fee of its own.
15.1 This membership does not provide, and is not a substitute for, emergency medical services. If Patient believes they are experiencing a medical emergency, Patient should call 911 or go to the nearest emergency department immediately. Clinic does not guarantee same-day, after-hours, weekend, or emergency appointments and does not provide 24/7 on-call coverage unless separately stated in writing.
16.1 Clinic will maintain Patient’s medical records in accordance with North Carolina Medical Board expectations and HIPAA. Upon written request, Clinic will provide Patient (or Patient’s authorized representative) access to and copies of Patient’s records within the time and subject to the reasonable, cost-based fees permitted by law.
16.2 If this Agreement terminates, Clinic will retain Patient’s records for the period required by law and will transfer copies of records to a subsequent provider upon Patient’s written authorization.
17.1 Patient concerns about care are best addressed directly with Clinic first. Patient also has the right to file a complaint with the North Carolina Medical Board (www.ncmedboard.org) and to file a HIPAA privacy complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Nothing in this Agreement, including Section 25 (Arbitration), limits or waives these rights.
18.1 All notices under this Agreement, including notice of cancellation or non-renewal, must be in writing and delivered by email (Clinic: admin@trianglelongevityclinic.com; Patient: the email address on file), by hand delivery, or by mail to the Clinic address shown on this Agreement or Patient’s address on file. Notices are effective upon actual receipt or, for mailed notice, three (3) business days after mailing.
19.1 Each Party agrees to act in good faith and refrain from knowingly false statements about the other. Nothing in this Agreement restricts Patient’s right to leave an honest review, rating, or complaint about Clinic’s services, or to make any report to a regulatory or governmental body, and this Section shall be interpreted consistently with the federal Consumer Review Fairness Act.
20.1 Clinic will not use Patient’s name, image, or health information in marketing or testimonials without Patient’s separate, specific, written, and revocable authorization. Declining to provide such authorization has no effect on Patient’s membership or care.
21.1 Clinic is not liable for delay or failure to provide services due to causes beyond its reasonable control, including illness or unavailability of the treating physician, natural disaster, or public health emergency. If the treating physician becomes temporarily unavailable, Clinic will arrange coverage for urgent clinical needs where reasonably possible. If the treating physician becomes permanently unavailable, Clinic will use reasonable efforts to arrange a successor provider or transfer of Patient’s care, and Patient will receive a prorated refund under Section 13.3.
22.1 Nothing in this Agreement creates an employment, partnership, or agency relationship between the Parties. Patient’s membership is personal to Patient and may not be transferred to another individual. Clinic may assign this Agreement in connection with a sale, merger, or transfer of its practice, upon written notice to Patient, subject to applicable healthcare and privacy laws.
23.1 To the fullest extent permitted by applicable law, Clinic’s aggregate liability arising out of the contractual obligations established by this Agreement (such as fees, scheduling, and membership administration) shall not exceed the membership fees actually paid by Patient during the twelve (12) months preceding the event giving rise to the claim. Nothing in this Section waives or limits liability for professional negligence, gross negligence, willful misconduct, or any other liability or patient right that cannot lawfully be waived or limited, and nothing in this Agreement alters the applicable standard of professional care.
24.1 This Agreement is governed by the laws of the State of North Carolina, without regard to conflict-of-laws principles. Subject to Section 25, any action not subject to arbitration shall be brought exclusively in the state or federal courts located in Wake County, North Carolina.
THIS SECTION AFFECTS YOUR LEGAL RIGHTS. SIGNING IT IS VOLUNTARY AND IS NOT REQUIRED TO RECEIVE CARE AT THIS CLINIC.
25.1 What This Means. If Patient agrees to this Section, Patient and Clinic each give up the right to sue the other in court, and the right to a jury trial, for the kinds of claims described below. Instead, those claims will be decided by a neutral arbitrator in a private proceeding under the Federal Arbitration Act, 9 U.S.C. §§ 1–16. Patient is encouraged to ask questions and to consult an attorney before signing.
25.2 Voluntary; Not a Condition of Care. Patient’s agreement to this Section is entirely voluntary. Declining or later cancelling this Section will not affect Patient’s membership, care, or the rest of this Agreement.
25.3 Right to Cancel. Patient may cancel this Section, with no effect on the rest of this Agreement, by written notice to Clinic within thirty (30) days after signing.
25.4 Scope. Subject to Section 25.6, this Section applies to any dispute arising out of or relating to this Agreement or the care Patient receives from Clinic, including claims of professional negligence, and survives termination of this Agreement.
25.5 Arbitrator and Procedure. Arbitration will be conducted by a single neutral arbitrator administered by JAMS under its applicable rules, or by another established, neutral arbitration organization agreed upon by the Parties in writing. If the administrator is unwilling or unable to administer the dispute, the Parties will select a neutral arbitrator by mutual agreement or, failing agreement, as provided by the Federal Arbitration Act. Clinic will pay the arbitrator’s fees and administrative costs in excess of the filing fee Patient would otherwise pay to file the claim in North Carolina state court.
25.6 Carve-Outs. This Section does not apply to, and does not limit: (a) either Party’s right to bring an individual claim in small claims court; (b) Patient’s right to file a complaint with the North Carolina Medical Board, the U.S. Department of Health and Human Services, or any other governmental body; or (c) any claim that cannot lawfully be subject to pre-dispute arbitration.
25.7 Individual Claims Only. Arbitration will proceed on an individual basis only. Neither Party may bring a claim as a class, collective, or representative action.
25.8 Acknowledgment. By initialing below, Patient confirms that the nature and effect of this Section were explained, that Patient had the opportunity to ask questions and to decline, and that Patient voluntarily agrees. If Patient does not agree, Patient should check “I decline” instead.
26.1 Entire Agreement; Order of Precedence. This Agreement, Schedule A, Clinic’s Terms of Medical Services, Notice of Privacy Practices, and any treatment-specific consent collectively govern Patient’s membership and receipt of medical services from Clinic. If documents conflict: (1) a treatment-specific consent controls as to that treatment; (2) this Agreement controls as to membership matters (fees, term, renewal, cancellation, refunds, and included services); and (3) the Terms of Medical Services control as to all other matters. This Agreement supersedes prior discussions concerning Patient’s membership.
26.2 Amendment. Except for fee changes upon renewal under Section 2.4, this Agreement may be amended only by a written document signed by both Parties. Updates to the Terms of Medical Services do not change Patient’s membership term, fees, renewal, cancellation, or refund rights.
26.3 Severability. If any provision of this Agreement is held unenforceable, the remaining provisions remain in full force and effect, and the unenforceable provision will be modified to the minimum extent necessary to make it enforceable. The unenforceability of Section 25 does not affect the remainder of this Agreement.
26.4 No Waiver. Failure to enforce any provision is not a waiver of that provision or any other provision.
26.5 Electronic Signature. This Agreement may be signed electronically and in counterparts, each of which is deemed an original.
By signing below, Patient acknowledges that Patient has read this Agreement in its entirety, including the automatic renewal terms and Schedule A, has had the opportunity to ask questions, and voluntarily agrees to its terms (except any section Patient has declined under Section 25).
This Schedule A is part of the Direct-Pay Membership Agreement. If this Schedule conflicts with the body of the Agreement, this Schedule governs only as to pricing.
| Membership Component | Coverage Period | Fee |
|---|---|---|
| Initial Consultation, Testing & Assessment (initial visit, baseline Labcorp testing panel, and individualized written care plan) | One-time; due at enrollment | $1,200.00 |
| Continued Membership & Follow-Up: 6-Month Term | 6 months; renews automatically | $3,500.00 (≈ $583.33 / month) |
| Continued Membership & Follow-Up: 12-Month Term | 12 months; renews automatically | $6,000.00 ($500.00 / month) |
The Initial Consultation, Testing & Assessment fee of $1,200.00 applies once, at enrollment, regardless of the plan selected, and is due before or at the time of the initial visit.
Each plan renews automatically for a term of the same length at the then-current fee unless either Party gives at least thirty (30) days’ written notice of non-renewal before the end of the term. Clinic will send a renewal reminder 15 to 45 days before each renewal (Section 2.3).
If Patient cancels during a term, Clinic will refund the amount attributable to each full calendar month remaining (Section 13):
Partial months are not refunded.
Additional testing, appointments, or services beyond those included in Patient’s plan will be billed separately. Clinic will tell Patient the fee in advance, and provide a Good Faith Estimate where required, before the item or service is provided.
Patient authorizes Clinic to charge the payment method on file for the fees above, including automatic renewal charges, additional-service fees Patient has approved under Section A.5, and late fees under Section 14, unless Patient cancels as described in Section 2 and this Schedule.
This web version contains the full text of the document. Signature, initial and checkbox lines are left out here and appear on the signable copy given to you at enrollment.
