Medical consulting services agreement & privacy policy V. Qcsa1

VCP REPRESENTATIONS AND CLIENT REQUIREMENTS

BEFORE you execute this agreement, you hereby state that you understand and agree to the following:

1. 
   VCP provides medical consulting for Veterans through the use of proprietary website software that determines the best VA claims development strategy through the use of a complex computer algorithm that processes dozens of variables.

   VCP technology also assists the Veteran by automatically populating various VA claim forms once the Veteran completes an online interview process on our website. The interview process also captures relevant information for our medical consultants to use in the development of supporting documents (Medical Opinions, Independent Rating Evaluations, Medical/Legal Considerations, etc.)

   The medical consulting package is prepared and then sent to the Veteran along with a copy of the computer generated VA forms that are automatically populated using the Veteran’s answers to the website interview questions.

   The Veteran is responsible for filing their claim(s) with the VA. We DO NOT file claims or represent the Veteran before the Department of Veterans Affairs however we do work closely with many VSOs, attorneys and agents so please don’t feel that you have to cancel your relationship with your VSO or agent/attorney.

   
   

To be able to effectively provide this service to our Veterans, beginning January 31, 2017, VCP requires ALL clients to:

1. 
   Have a basic comfort level using a web browser on either a computer, tablet, or smartphone
   
2. 
   Maintain a personal email account that the Veteran checks on a daily basis
   

1. 
   Has a personal cell phone with text messaging capabilities AND authorizes VCP to communicate with the Veteran through text message
   
2. 
   Obtain & maintain a PREMIUM VA eBenefits account at all times (sign up for a FREE PREMIUM account at ebenefits.va.gov or ask your Intake Specialist for guidance on setting it up)
   
3. 
   Submit various VA Benefit related information to VCP upon request {$Initials}
   
   
   
1. 
   Veteran agrees to email Awards@vetcompandpen.com or submit via web link provided in the request, a screenshot of their VA pay history off eBenefits within seventy-two (72) hours of executing this agreement. {$Initials}
   
   
   
2. 
   Veteran agrees to email Awards@vetcompandpen.com or submit via web link provided in the request, screenshots of Veterans VA pay history off eBenefits within the first 2 days of each calendar month and within two (2) days of request by VCP. {$Initials}
   
   
   
3. 
   Veteran agrees to email Awards@vetcompandpen.com or submit via web link provided in the request, copies of all VA Rating Decision Letters, VA Award Letters and VA Rating Breakdown Letters, upon execution of this agreement and upon receipt of new letters within two (2) business days of receipt. VCP will provide Veteran with detailed instructions to assist the Veteran in obtaining the above information. {$Initials}
   

The VA is rapidly moving into the digital world. Due to various deadlines imposed by the VA, (some of which are as short as two weeks) VCP must be provided the above information in a timely manner to help maintain our standards and to assist as many Veterans as possible.

VCP chooses to work ONLY with Veterans who are serious about their VA claims and willing to work as hard as we are to help them receive all the benefits they are legally and ethically entitled to. We have far too many clients on our waiting list to expend our resources trying to assist an uncooperative Veteran when there are countless Veterans who are serious about their case and willing to provide us what we need in a timely manner to help move their case forward.

On average, it takes us approximately 3 to 4 separate rounds of claims to get our clients to the ultimate VA disability rating they deserve. One missed deadline or misjudgment due to lack of full information could cost the Veteran thousands of dollars in missed benefits as well as delays that could last up to 8 years or longer with untold frustrations for our Veterans and our team members.

Since there is so much at stake for all parties involved, VCP requires ALL of our Veteran clients to comply, in a timely manner, with ALL of our requests for the information we feel is necessary for us to fully execute this contract and maximize our services to our clients.
Failure to comply with ANY such requests may result in VCP terminating this agreement and permanently BLACKLISTING the Veteran as a client at any time, even if several rounds of claims are needed to receive the ultimate VA rating. {$Initials}

VETERANS COMMITMENT AND REPRESENTATIONS

1. 
   Veteran understands ALL interactions with the Department of Veteran Affairs on topics relating to disability claims could have a significant impact on the processing or award of any pending claims as well as the strategy developed by our proprietary system. {$Initials}
   

2. 
   Veteran agrees to follow the strategic approach developed by the proprietary claims strategy algorithm that is built into our website and commits to refrain from filing claims that are not consistent with the proposed strategy until the Veteran completes the recommended approach that is provided to the Veteran.
   

3. 
   Veteran understands that as his/her medical consultants, VCP must be informed of all medical appointments, changes in health or medical conditions, VA Award Letters and Rating Decision Letters as soon as the Veteran becomes aware of them. {$Initials}
   

4. 
   Veteran will advise VCP of any scheduled VA C&P exams as soon as the Veteran receives notice of the C&P exam appointment. {$Initials}
   

5. 
   Veteran acknowledges that this contract is not cancelable once VCP begins working on your claim. Since VCP does not charge the Veteran ANY up front medical consulting fees, VCP agrees to work in advance, based on your commitment to follow through with the claims process and pay fee to VCP after an award is received from the VA.

   In the event Veteran fails to follow through with this agreement, there will be breach of contract fee owed to VCP in the amount of $400 per hour VCP staff has spent on the Veteran’s claims OR the full projected fee VCP would have earned in this agreement, had it been honored, whichever is greater. {$Initials}

   
   

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TERMS OF SERVICES PROVIDED BY

VET COMP & PEN MEDICAL CONSULTING

1. 
   Our medical consulting fees are for “Pre­Filing VA Disability Claim Medical Consultation” relating to medical conditions that may potentially impact our Veteran clients. VCP provides our clients free­of­charge access to software to assist our Veteran clients in preparing and submitting various forms to the VA.
   
2. 
   Any and all claim preparation assistance is provided exclusively via automated software that our clients utilize and we NEVER charge a fee for the preparation of a claim. All claims must be reviewed by the Veteran for accuracy and signed prior to being submitted to the VA by the Veteran. Veteran is solely responsible for ensuring that all filings the Veteran makes with the VA are accurate and timely. Veteran releases VCP from any responsibility associated with the accuracy or timeliness of any filing made by the Veteran with the VA.
   
3. 
   VCP will review your military and civilian medical records, C­File documents, and medical case history as VCP deems necessary and will provide medical consulting services to you and/or your legal attorney/advocate if applicable.
   
4. 
   VCP does NOT guarantee you or your legal attorney/advocate that we will accept your case and provide medical consulting. Some cases are not appropriate for our services.
   
5. 
   VCP does NOT guarantee that your case or claim will prevail and be approved by the VA. Veteran understands that VCP makes no promises or representations as to what your case or claim will ultimately be worth and no employee or agent of VCP, other than the CEO has the authority to bind, commit or extend promises to a Veteran.
   
6. 
   VCP has a team of medical and legal professionals who review your case and write Medical Opinions, Independent Rating Evaluations, and assist you in preparing your Lay Statement in Support of the Claim.
   
7. 
   On a case­by­case basis, VCP may assist a Veteran with any pending claims that have been filed prior to the signing of this agreement but have not yet been adjudicated by a VA REGIONAL OFFICE. Veteran understands and agrees to compensate VCP for any pending awards that Veteran has filed with the VA if that award is adjudicated after executing this agreement. VCP STRONGLY PREFERS NOT TO WORK CASES THAT HAVE PENDING CLAIMS IN THE SYSTEM THAT HAVE NOT YET BEEN ADJUDICATED BY THE VA.
   
8. 
   Once VCP assists you in getting a new claim service connected, VCP will help you protect that claim from being lowered FOR YOUR LIFETIME ­ AT NO ADDITIONAL CHARGE.
   
9. 
   VCP is available to assist Surviving Spouses to receive approximately $15,000 per year for their lifetime in the event their Veteran spouse died from a service connected disability.
   
10. 
    VCP does NOT charge you for preparation of case files, such as copy fees, mailing fees, etc., nor does VCP charge you any up­front fees for the work it does.
    
11. 
    VCP NEVER charges you a fee unless either you have a favorable outcome on your claim that leads to an increase in your monthly disability award OR results in the protection of an award granted prior to VCP involvement that the VA was attempting to reduce.
    
12. 
    In the event you have a specific Mental Health Claim requiring an Independent Medical Opinion by a specialized mental health professional who holds the specific VA required credentials (i.e. Psychiatrist), you may be given the option to use a private provider OR use the VA staff doctors. If you choose to use a private provider, that provider may charge you a fee for their services, which is totally independent of VCP and our medical consulting services. The fee will be paid directly to the private medical provider and not VCP. This is OPTIONAL and not required, however many Veterans have found the expedited processing times and convenience are more than worth the nominal expense paid to the private provider.
    
13. 
    VCP does not file your claim for you; either you or your attorney/advocate are responsible for filing your claims with the VA and you are SOLELY RESPONSIBLE for ensuring all time sensitive responses to VA denials, notices and rulings (Notice of Disagreement, Form 9, etc.) are filed within the appropriate timelines allowed by the VA.
    
14. 
    VCP provides Medical Consulting Services and is NOT your VA representative. VCP does NOT represent you before the VA as an advocate or a legal representative and does not provide legal advice.
    
15. 
    Once you execute this agreement, VCP will begin expending significant resources on your case. Since we do NOT charge any up­front fees, this agreement cannot be terminated by the Veteran without express written approval to terminate by VCP. VCP will not unreasonably withhold approval to terminate this agreement once all pending casework has been fully adjudicated by the VA (including through the appeals process if applicable).
    
16. 
    VCP agrees to work in advance, based on your commitment to follow through with the claims process and pay fees to VCP after an award is received from the VA. In the event you fail to follow through with this agreement, there will be breach of contract fee owed to VCP in the amount of $400 per hour VCP staff has spent on your claims OR the full projected fee we would have earned in this agreement, had it been honored, whichever is greater.
    

Disclaimer of Warranties: EXCEPT AS OTHERWISE PROVIDED HEREIN, VETERAN UNDERSTANDS AND AGREES THAT THE SERVICES ARE PROVIDED "AS IS" AND VCP EXPRESSLY DISCLAIMS ALL WARRANTIES OF ANY KIND, WHETHER EXPRESS, IMPLIED, STATUTORY OR OTHERWISE.

1. 
   Provide CREDIBLE and UNBIASED Independent Medical Opinions based upon the history that the Veteran provides, the available medical legal evidence and the independent medical assessment.
   

2. 
   Every medical professional associated with VCP has the sole authority and freedom to conclude that a claim lacks credible evidence to establish a service connection without fear of negative repercussions.
   

3. 
   This is why our Independent Medical Opinions carry significant weight before the VA and provide such value to our Veteran clients and their attorneys/advocates who may represent them; it is a KEY to us helping you win ALL of your VALID CLAIMS.
   

4. 
   VCP offers NO GUARANTEE that the medical opinion will be “favorable” to the Veteran’s VA claim. If there is insufficient medical or legal evidence to support your claim, VCP’s Independent Medical Opinion may be “inconclusive” or “unfavorable” and provide NO VALUE relative to the referenced claim.
   

5. 
   VCP DOES NOT control or dictate what is documented by one of our associated medical professionals in their Independent Medical Opinions and we provide NO GUARANTEE THAT THE INDEPENDENT MEDICAL OPINION WILL SUPPORT YOUR VA CLAIM AND/OR APPEAL.
   

6. 
   At VCP, our mission is to continue to assist Veterans in uncovering legitimate service connected disabilities and securing the necessary documentation that is formatted in proper medical / legal fashion for submission by the Veteran to the Department of Veteran Affairs.
   

7. 
   This is accomplished through a large network of Independent Medical Professionals who provide CREDIBLE and UNBIASED Independent Medical Opinions and documentation with a high professional standard of quality AND integrity. {$Initials}
   

STANDARD FEES AND PAYMENT TERMS

NOTE: There are specific additional supplements to the standard fee charges noted in the SUPPLEMENTAL FEES AND PAYMENT TERMS section below that applies to select Veterans.

EXAMPLE OF HOW WE CALCULATE FEES – SCENARIO 1:

A Veteran that is married and has no dependents and is currently rated at a 50% rating by the VA. He has applied for a new claim that has never been denied before, receives an increase to an 80% rating and is also awarded Special Monthly Compensation (SMC) at $101.50 per month.

Thus, the Veteran's total payment for services rendered is:

Pre­VCP Consulting: 50% = $917.13

Post­VCP Consulting 80% = $1,680.48 + $101.50 for SMC = $1,781.98

Difference in above (monthly increase) is [$1,781.98 - $917.13] = $864.85 x 5 months =

TOTAL FEE OWED TO VCP = $4,324.25
The Total Fee Owed to VCP can be Paid in Full (REQUIRED when Veteran receives a Retroactive Payment that is greater than VCP’s fee) OR paid as follows:



When enrolled in the VCP’s Automatic Monthly ACH Billing Program, this is payable over ten (10) monthly installments equal to ½ of the monthly increase or $432.43/mo.



Not enrolled in the VCP’s Automatic Monthly ACH Billing Program, this is payable over ten (10) monthly installments equal to ½ of the monthly increase plus 24.00% APR interest and $20 processing fee per payment or $538.92/mo.

I understand and agree with the calculations for the standard fees owed to VCP and the payment terms. {$Initials}

SUPPLEMENTAL FEES AND PAYMENT TERMS

Veterans who fall into one of the following categories are responsible for the associated supplemental fees detailed below:

1. 
   Receiving military retirement pay and currently are being paid at a total disability rating of 10% to 40%. NOTICE: A Veteran collecting monthly military retirement is not eligible for Concurrent Retirement Disability Pay (CRDP) above their retirement pay until the service connected disability rating reaches 50% or higher. As a result of the CRDP impact, your fees to VCP will be dependent on whether we help you get up to that critical 50% rating threshold.
   

If after working with VCP you DO NOT obtain the 50% threshold, which allows you to receive both your retirement pay and your VA disability pay, then you WILL NOT owe VCP anything for our services.

If VCP is able to help you obtain the 50% threshold, you will go from essentially receiving nothing for your VA service connected disability (other than some favorable tax benefits) to receiving both retirement pay AND disability pay each month. Instead of paying the Standard Fee noted above, you hereby agree to pay VCP five (5) months’ worth of the TOTAL VA DISABILITY CHECK paid to you each month by the VA when you reach the 50% or higher disability rating. {$Initials}

2. 
   You want VCP to protect an existing Service Connected Disability Rating that VCP did not participate in attaining.
   

NOTICE: Since VCP did NOT participate in helping you secure the initial disability award rating, this claim is not covered by VCP's lifetime commitment to provide FREE medical consulting services to defend and protect your VA disability ratings that we previously helped you secure. VCP will help you protect ratings that you had established prior to working with VCP for the following fee schedule.
The VA letter that notified you of the VA's intent to reduce your rating will detail which service connected disability rating is involved. VCP will determine the impact losing that rating will have on your disability compensation and will advise you of such. If you choose to proceed and have VCP prepare the medical consulting package for you to present to the VA, you will be responsible for paying VCP five (5) months’ worth of the protected rating no later than 90 days after VCP provides you the complete consulting package. In the event that you are not able to pay that fee in full at that time, you agree to pay 10% of the total fee each month beginning the month after you file the response to the intent to reduce so your balance will be paid in full no later than 10 months after the response to the intent to reduce has been filed with the VA. {$Initials}

3. 
   You have a claim that has previously been denied and is on appeal.
   

NOTICE: Since these cases often involve significant additional work to "undo" the previous unsuccessful attempts to secure an award for service connection, and they often require additional medical and legal evidence to be developed, in addition to the standard five (5) months’ worth of the increased monthly benefit detailed in the above Standard Fee Charges and Payment Terms, you agree to pay VCP 10% of the total gross retroactive (before any legal or other fees are deducted) award within two (2) business days of receiving payment on your claim. {$Initials}

4. 
   You have a CUE or Clear and Unmistakable Error claim.
   

NOTICE: Few Veterans have these claims in their files and even fewer still are aware of these claims. In the event we help uncover a CUE claim, the VA will be responsible for paying you retroactive pay to the initial date that the VA made the error. In these cases, you agree to pay us five (5) months’ worth of the highest monthly value of the CUE claim award PLUS 25% of the total gross retroactive pay (before any legal or other fees are deducted) due within two (2) business days of receiving payment on your claim. {$Initials}

5. 
   Your case requires a specific Medical Opinion or other custom medical documentation.
   

NOTICE: Due to the significant additional work and expertise required for these documents, in addition to the standard five (5) months’ worth of the increased monthly benefit detailed in the above Standard Fee Charges and Payment Terms, you agree to pay VCP 10% of the total gross retroactive (before any legal or other fees are deducted) award within two (2) business days of receiving payment on your claim. {$Initials}

6. 
   You have pending claims that have not yet been adjudicated by the VA or you file additional claims on your own.
   

NOTICE: Any pending claims that have been filed prior to signing this agreement that have not been adjudicated by the VA, and additional claims that you file on your own without VCP's assistance can dramatically impact the viability of your case. These types of claims often add significant workload for VCP and can adversely impact the case strategy etc. Due to this, VCP would prefer NOT to work on cases that have pending claims that have yet to be adjudicated by a VA Regional Office and we would prefer to pass on cases where the Veteran intends to file additional claims on their own. HOWEVER, if the Veteran wishes to proceed and not wait for those claims to finish routing through the system, you hereby understand that VCP will participate in ANY increased award from any pending claims the Veteran filed with the VA prior to executing this agreement or any pending claims the Veteran filed with the VA prior to executing this agreement or any new claims the Veteran files with or without VCP's assistance after this agreement is filed up until the active claims VCP is working on with the Veteran are fully resolved and VCP advises the Veteran that no further case development is viable. We encourage you to NOT execute this agreement if you have any pending claims and are not comfortable with VCP participating in the potential pending award. As of the effective date of this agreement, VCP’s fee will be due regardless of whether the Veteran has a pending claim, or whether VCP initiates the claim. History has proven that these cases are typically a mess and extremely time consuming. VCP's fee for these cases is five (5) months’ worth of the increase in benefit for any previously filed claims or any claims the Veteran files on their own while still waiting for final adjudication on active claims VCP is assisting with. Payment shall be sent to VCP at the address at the top of this agreement within two (2) business days of receipt of the increased monthly benefit award from the VA every month until VCP's fees are paid in full.
For example, if you are currently getting paid at the 10% pay scale rate and you have a pending claim that VCP did not assist you with that becomes approved, causing you to move up to the 50% pay scale level, you agree that you would be responsible for paying VCP five (5) months’ worth of the increase in pay from the 10% to the 50% even though you filed that claim without VCP's assistance. {$Initials}

7. 
   You are receiving a temporarily increased rating (due to convalescence you are receiving 100% pay for 12 months while you recover from a surgery, stroke or heart attack etc.).
   NOTICE: The calculations for this agreement are based on the rating and pay level you had prior to the temporary increased rating since your temporarily increased convalescence rating will revert to the prior rating, or potentially even lower than that, if the VA argues the condition has improved. You agree to pay VCP's fee based on the difference between the disability rating you were receiving prior to the temporary bump for the convalescence rating and the newly awarded rating you receive after VCP's medical consulting assistance. These cases generally require specific medical opinions so you will also be responsible for paying the additional 10% of the retroactive lump sum award detailed in #5 above. {$Initials}
   

8. 
   In the event you are awarded a temporary convalescent rating.
   

Since these ratings are temporary in nature, VCP will NOT receive the standard five (5) months’ worth of the monthly increased award you receive. Instead, you agree to pay VCP 20% of your gross total increased award during the temporary convalescent period. {$Initials}

For example, if your monthly VA disability pay increases from $1,500/mo. to $3,200/mo. for a period of 12 months, your gross total increased award during the temporary 12 month period is $3,200­$1,500=$1,700 X 12 mo. = $20,400. You agree to pay VCP 20% of that gross total increased award which is equal to a fee of $4,080 payable to VCP.

EXAMPLE OF HOW WE CALCULATE FEES ­ SCENARIO 2:
A Veteran that is married and has no dependents is currently rated at 50% rating by the VA. He receives an increase to 90% after the Veteran wins an appeal that was four years old.
Thus, the Veteran's total payment for services rendered: Pre­VCP Consulting: 50% = $917.13

Post­VCP Consulting: 90% = $1,888.48

Difference in above (monthly increase) is [$1,888.48 - $917.13] = $971.35 x 5 months’ worth of payment = $4,856.75

Veteran also receives a retroactive gross award of $82,867.20 for the four year old appeal, before legal fees and other deductions: 10% of $82,867.20 = $8,286.72
The TOTAL payment due will be $8,286.72 (10% of retroactive award) + $4,856.75 (5 months of new monthly gain) =
TOTAL FEE OWED TO VCP = $13,143.47
The Total Fee Owed to VCP MUST BE PAID IN FULL WITHIN 5 Days of Veteran’s receipt of payment from the VA since the Veteran’s Retroactive Pay is greater than VCP’s fee.
The above are examples to illustrate how the VCP’s fees are calculated and paid. There is a wide range of potential outcomes for the fees payable to VCP that can range from zero to tens of thousands of dollars if you receive a substantial lump sum retroactive award.
I understand and agree with the calculations for the supplemental fees owed to VCP and the payment terms ­ {$Initials}
EXAMPLE OF HOW WE CALCULATE FEES ­ SCENARIO 3:
A retired Veteran that is married and has no dependents is currently rated at 20% rating by the VA. He receives an increase to 90% after filing claim assisted by VCP.
Thus, the Veteran's total payment for services rendered:

Pre­VCP Consulting: $3,200 retirement + (20% at $317.13) = $3,200

Post­VCP Consulting: $3,200 retirement + (90% at $1,888.48) = 5,800.48

Difference in above (monthly increase) is [$8,800.48 - $3,200] = $1,888.48 x 5 months’ worth of payment = $9,442.40 (plus 10% of retroactive pay)

The TOTAL payment due will be $9,442.40 (five (5) months of new monthly gain)

The Total Fee Owed to VCP can be Paid in Full (REQUIRED when Veteran receives a Retroactive Payment that is greater than VCP’s fee) OR paid as follows:



When enrolled in the VCP’s Automatic Monthly ACH Billing Program, this is payable over ten (10) monthly installments equal to ½ of the monthly increase or $944.24/mo.



Not enrolled in the VCP’s Automatic Monthly ACH Billing Program, this is payable over ten (10) monthly installments equal to ½ of the monthly increase plus 24.00% APR interest and $20 processing fee per payment or $1,190.86/mo.

I understand and agree with the calculations for the standard fees owed to VCP and the payment terms. {$Initials}

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Miscellaneous

1. 
   Entire Agreement, Modifications, and Waivers. This Agreement contains the entire agreement between VCP and Veteran with respect to the subject matter hereof. This Agreement may not be modified except by written instrument signed by both Parties and referring to the particular provisions to be modified. If any provision of this Agreement is declared invalid or unenforceable, then the court shall replace the invalid or unenforceable provision with a valid and enforceable provision that most accurately reflects the Parties’ intentions and the remaining provisions of this Agreement shall remain in full force and effect. Failure by either Party to enforce any provision of this Agreement will not be deemed a waiver of future enforcement of that or any other provision. Wherever the term “including” is used, it shall mean “including, but not limited to”. This Agreement may be executed in one or more counterparts, each of which shall be deemed an original for all purposes, and together shall constitute one and the same agreement.
   
   
   
2. 
   Headings, Advice of Counsel, and Drafting. Headings used in this Agreement are provided for convenience only and will not in any way affect the meaning or interpretation of each section. The Parties acknowledge that they have been advised by counsel of their own choosing or have had the opportunity to consult such counsel, and therefore waive any canons of construction that would construe this agreement more heavily in favor of one party over the other, and that its terms will be interpreted without any bias against one Party as drafter.
   
   
   
3. 
   Governing Law, Disputes. This Agreement shall be governed and construed exclusively by and under the laws of the State of Florida, without regard to its conflicts of laws rules. The state and federal courts located in Alachua County, Florida, shall have exclusive jurisdiction to adjudicate any dispute arising out of or relating to this Agreement. Each Party hereby consents to the exclusive jurisdiction of such courts. In any dispute arising out of relating to this agreement, the prevailing party shall be entitled to recover its attorney fees and reasonable costs. If Veteran refuses to pay VCP as agreed, Veteran also agrees to pay VCP the costs of collection of such debt, including reasonable court and attorney fees and costs.
   
   
   
4. 
   Standard Forms 180, 4138, and Written, Electronic & Telecommunications with the VA. Veteran understands and agrees that to fully assist in the identification of all eligible benefits and to fully execute all aspects of this Medical Consulting Agreement; Vet Comp & Pen Medical Consulting will need access to private information regarding the Veteran’s VA claims file including pending, awarded, and denied claims. Veteran hereby agrees to provide, and or allow VCP to verify any and all needed information to pursue the full execution of this contract and will provide an executed blanket VA SF180 or 4138 and will provide or request the delivery of the necessary records VCP may request from time to time. Veteran authorizes VCP, for the purposes of medical consulting and full satisfaction of this agreement, to access all of the Veteran’s information and/or records at the Department of Veterans Affairs. Upon the full satisfaction of this agreement the above authorizations will expire.
   

I, VETERAN {$Name}, PROMISE TO PAY VCP the total sum owed for medical consulting services provided, as outlined above in the Standard and Supplemental Fees and Payment Terms sections of this document. My payment will be calculated based on the equation above. In the event of my death prior to the completion of my case, I agree that my estate will be financially liable to provide payment for medical consulting services rendered.

I understand that within five (5) business days following receipt of any additional benefit payment from the VA, I must either:

1. Pay the Total Sum Owed in full (REQUIRED when Veteran receives a Retroactive Payment that is greater than VCP’s fee)
   
   

2. Enroll in VCP’s Interest Free Automatic Monthly ACH Billing program to make 10 equal monthly withdrawals commencing on the next VA monthly payment day
   
   

3. Make 10 monthly payments commencing on the first VA monthly payment day immediately following my award equal to 1/10 of the Total Sum Owed PLUS a 24.00% APR interest rate and $20 processing fee per payment

Failure to make payments according to the above terms will subject the outstanding balance due to a 15% per month compounding interest rate, or the maximum permitted by law, whichever is less, plus all expenses of collection, for any unpaid balances. I agree to pay the aforementioned interest rate increase and expenses of collection if I do not pay VCP in accordance with the terms and conditions above.

I hereby agree to hold Vet Comp and Pen Medical Consulting, LLC, Directors, Managers, and Staff, harmless for any losses or damages or any other liability whatsoever suffered or incurred by me or my heirs regardless of cause. I specifically understand that I am 100% responsible for ensuring that I file any and all claims and necessary responses, appeals, or disagreements in a timely manner with the VA and VCP does NOT file any type of responses or documents on my behalf. I hereby authorize VCP to contact me via phone and text messages, automated calling for reminders, etc., and authorize VCP to discuss matters related to my claims with my family members, emergency contact person, or any referring or referred parties as VCP pursues the complete satisfaction of this agreement.

Confidentiality and Non­Disclosure. I hereby acknowledge that the medical consulting performed by VCP or VCP affiliated medical professionals, along with all copyrights, etc. are exclusively owned by Vet Comp & Pen Medical Consulting, LLC and I am hereby restricted from publishing, reproducing, distributing or sharing any of the documents produced with any party other than the VA unless specifically instructed to do so in writing by VCP. I hereby understand that breech of this confidentiality and non­disclosure may cause extensive financial damage to VCP or other Veterans and I will be held liable for such breach.
In the event VCP has difficulty reaching me regarding an urgent matter, the following person will ALWAYS know how to get in touch with me:

Name: {$Contact_Name} Phone: {$Contact_Phone} Email: {$Contact_Email}

My current Total VA Service Connected Disability Rating Percentage (%) that the VA is paying me at is: {$PercentPay}

I am currently receiving $ {$MoneyPer} per month from the VA for disability pay.

My discharge status from the military is (or will be): {$MilitaryStatus}.
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the time and date this document is electronically signed.
Signed By: {$Name}
Veteran’s Signature: {$Signature|image:1:png} Date: {$Date}

PRIVACY POLICY FOLLOWS ON NEXT PAGE

PRIVACY POLICY

This Notice provides information about the use and disclosure of protected health information (“PHI”) by Vet Comp and Pen Medical Consulting Services, LLC (“VCP” or “Provider”). This Notice applies when services are provided by VCP. This Notice also describes your rights and our obligations for using your health information, informs you about laws that provide special protections, explains how your PHI is used and how, under certain circumstances, it may be disclosed, and tells you how changes to this Notice will be made available to you.

Protected Health Information. This Notice applies to protected health information (“PHI”) created or received by VCP that identifies you; relates to your past, present, or future physical or mental condition; relates to the care provided; or relates to the past, present or future payment for your healthcare. For example, PHI includes your symptoms, test results, diagnosis, treatment, health information from other providers, and billing and payment information relating to these services. This information, often contained in your medical record, serves, among other purposes, as a means of communication among the many health professionals who contribute to your care, and the legal record describing the services you received.

Understanding what is in your record and how your health information is used and disclosed helps you to:

1. 
   Ensure accuracy in the record.
   
2. 
   Better understand who, what, where, and why others may access your health information.
   
3. 
   Make a more informed decision when authorizing disclosures to others.
   

Use and Disclosure of Your Protected Health Information (“PHI”) Without Your Authorization. We may use and disclose your PHI without your written authorization for the following reasons:

1. 
   To provide medical assessments, for example, a VCP staff member may use your PHI to assess your current health condition.
   
2. 
   We may disclose your PHI to another one of your treatment providers in the community.
   
3. 
   For payment purposes, for example, we may use your PHI to prepare claims for payment of services you have received.
   
4. 
   For healthcare operations, we may use and disclose your PHI to support daily activities related to healthcare, for example, to monitor and improve our health services or for authorized staff to perform administrative activities.
   
5. 
   To train staff, for example, our experienced medical professionals review PHI with other VCP staff/employees.
   
6. 
   To contact you for more information, your PHI may be used to contact you, call you or send you a letter to remind you about appointments, provide medical assessment results, inform you about your options or advise you about other health related benefits and services.
   
7. 
   Joint Activities, your health information may be used and shared by VCP to further their joint activities and with other individuals or organizations that engage in joint payment or health­care operational activities with VCP. Health information is shared when necessary to provide medical assessment services, secure payment for medical assessment services, and perform other joint health­care operations such as peer review and quality improvement activities, accreditation related activities, and evaluation of trainees.
   
8. 
   Business Associates, your health information may be used by VCP and disclosed to individuals or organizations that assist VCP or to comply with their legal obligations as described in this notice. For example, we may disclose information to consultants or attorneys who assist us in our business activities. These business associates are required to protect the confidentiality of your information with administrative, technical and physical safeguards.
   
9. 
   Other Uses and Disclosures, we also use and disclose your information to enhance healthcare services, protect patient safety, safeguard public health, ensure that our facilities and staff comply with government and accreditation standards, and when otherwise allowed by law. For example, we provide or disclose information:
   
   1. 
      To government oversight agencies with data for health oversight activities such as auditing or licensure
      
   2. 
      To appropriate government agencies when we suspect abuse or neglect
      
   3. 
      To appropriate agencies or persons when we believe it necessary to avoid a serious threat to health or safety or to prevent serious harm
      
   4. 
      To law enforcement when required or allowed by law
      
   5. 
      For court order or lawful subpoena
      
   6. 
      To coroners, medical examiners and funeral directors
      
   7. 
      To government officials when required for specifically identified functions, such as national security
      
   8. 
      When otherwise required by law, such as to the Secretary of the United States Department of Health and Human Services for purposes of determining compliance with our obligations to protect the privacy of your health information
      
   9. 
      If you are an active member of the armed forces, we may release medical information about you as required by military command authorities
      

**We will not sell, trade, or loan your information to any third parties, but may share it with third parties working on your VA disability claim(s) that also provide you professional medical services or legal services (typically in the event one of your claims has been denied by the VA).

Use and Disclosure When You Have the Opportunity to Object. Disclosure to and Notification of Family, Friends or Others, unless you object, we will use our professional judgment to provide relevant protected health information to person(s) (such as a family member, spouse, friend) that has indicated an active interest in your VA disability benefits or the payment for your medical consulting services or who may need to notify others about your location, general condition or death.
Use and Disclosure Requiring Your Authorization. Other than the uses and disclosures described above, we will not use or disclose your protected health information without your written authorization. VCP requires your written authorization for marketing (other than a face­to­face communication between you and a VCP workforce member), or before selling your protected health information. If you provide us with written authorization, you may revoke it at any time unless disclosure is required for us to obtain payment for services already provided, we have otherwise relied on the authorization, or the law prohibits revocation.
Additional Protection of Your Patient Health Information. Special state and federal laws apply to certain classes of patient health information. For example, additional protections may apply to information about sexually transmitted diseases, drug and alcohol abuse treatment records, mental health records, and HIV/AIDS information. When required by law, we will obtain your authorization before releasing this type of information.
Your Individual Rights about Patient Health Information. You have rights related to the use and disclosure of your protected health information. To contact the Providers to exercise your rights, you may contact:
VCP Chief Security Officer

410 SW 140th Terrace

Newberry, FL 32669
Your specific rights are listed below:

1. 
   The right to request restricted use: You may request in writing that we not use or disclose your information for assessment, treatment, payment, and/or operational activities except when authorized by you, when required by law, or in emergency circumstances. We are not legally required to agree to your request. If you make your request to VCP, we will provide you with written notice of our decision about your request.
   
2. 
   The right to receive confidential communications: You have the right to request that we communicate with you about medical matters in a particular way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the address above. We will grant all reasonable requests. Your request must specify how or where you wish to be contacted.
   
3. 
   The right to inspect and receive copies: In most cases, you have the right to inspect and receive a copy of certain healthcare information including certain medical and billing records. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
   
4. 
   The right to request an amendment to your record: If you believe that information in your record is incorrect or that important information is missing, you have the right to request in writing that we make a correction or add information. In your request for the amendment, you must give a reason for the amendment. We are not required to agree to the amendment of your record, but a copy of your request will be added to your record.
   
5. 
   The right to know about disclosures: You have the right to receive a list of instances when we have disclosed your health information. Certain instances will not appear on the list, such as disclosures for treatment, payment, or health­care operations or when you have authorized the use or disclosure.
   
6. 
   The right to make complaints: If you are concerned that we have violated your privacy, or you disagree with a decision we made about access to your records, you may file a complaint with the entity that provided services to you. Alternatively, you may file a complaint with the VCP Chief Security Officer using the contact information above. VCP will not retaliate against anyone for filing a complaint.
   

If you believe that your privacy rights have been violated, you may also contact the U.S. Department of Health and Human Services, Office for Civil Rights.

Office for Civil Rights, U.S. Department of Health and Human Services

Sam Nunn Atlanta Federal Center, Suite 16T70

61 Forsyth Street, S.W., Atlanta, GA 30303­8909

Voice Phone (800) 368­1019, FAX (404) 562­7881, TDD (800) 537­7697

Our Legal Duties. We are required by law to protect the privacy of your information, notify affected individuals following a compromise of unsecured protected health information, provide this Notice about our privacy practices, and follow the privacy practices that are described in this Notice.
Privacy Notice Changes. We reserve the right to change the privacy practices described in this Notice. We reserve the right to make the revised or changed Notice effective for protected health information we already have as well as any information we may receive in the future. We will post a copy of the current Notice at each VCP entity and at each VCP facility. In addition, each time you register at, or are admitted to VCP for medical assessments or health care services, you may request a copy of the current Notice from the location of your care provider or you may request a copy of this Notice from the VCP Chief Security Officer. An electronic version of the notice is posted at.
I understand and agree with the Vet Comp & Pen Medical Consulting Privacy Policy. {$Initials}

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