Self-Pay Agreement
Provider Name: Trak Fertiliy
Consumer Name: [PATIENT_NAME]
SERVICE: Male Fertility Test (“Service”)

This constitutes a valid and binding agreement among the parties (“Agreement”).
The Consumer or his/her authorized representative used LabFinder.com or its mobile app to find and book the services he/she needs at an agreed upon price.
The Provider agrees to provide to the Consumer the above Service for a total self-pay payment price of: $[TOTAL_CHARGE]. The Provider accepts such price (the “Service Charge”) due it as payment in full.
Consumer further agrees to pay LabFinder $[CONVENIENCE_CHARGE] for its technological facilitation herein (the “Convenience Charge”).
Consumers are charged for full balance of the Service Charge and Convenience Charge, respectively, at the moment the Provider accepts their booking or order. (See Cancellation and Refund Policy below)
EACH OF PROVIDER AND CONSUMER REPRESENT, WARRANT AND COVENANT THAT THEY WILL NOT SUBMIT ANY BILLS OR CLAIMS FOR PAYMENT OR REIMBURSEMENT TO ANY PRIVATE OR GOVERNMENTAL PAYOR OR CARRIER FOR THE SERVICE RENDERED HEREIN.
This arrangement is only for the above-named Consumer for the stated Service with the above-named Provider. LabFinder has no responsibility or liability for products shipped, including, without limitation, with respect to delivery, receipt, return, damage or loss. Consumers acknowledge that the test results for this Service are not published on the LabFinder platform. Provider is solely responsible for sharing the results with the Consumer.
If the actual service or product required to test or treat the Consumer is different from that listed above, then Provider must inform Consumer what the new/additional service or product is and what the price will be before rendering testing or treatment.
If the Service is billed in several parts or from different sources, the total Service Charge will nevertheless add up to the agreed upon Service price above. Provider will hold Consumer harmless from and against any attempt (successful or otherwise) by a third party source to collect any excess amounts resulting in additional payment obligations by the Consumer beyond the total Service Charge pricing for the Service as set forth above (Note: This does not apply to amounts owed LabFinder by Consumer hereunder).
Provider represents and warrants that it is fully qualified, credentialed, registered and otherwise licensed to render all Services agreed upon herein for the above Consumer.
CANCELLATION AND REFUND POLICY:
All amounts agreed to be paid hereunder are NON-REFUNDABLE.
FURTHER ACKNOWLEDGMENTS AND AGREEMENTS:

1. “LABFINDER, LLC” (“LabFinder”; sometimes “we”, “our” or the like) is inclusive of LabFinder, LLC and its successors, LabFinder.com and all associated websites and mobile applications (apps).
2. If Consumer cancels or disputes a charge or payment except as otherwise permitted under this Agreement, each of LabFinder and Provider respectively shall be entitled to reimbursement from Consumer and the undersigned (as a legal representative and signatory hereto if different than Consumer) of all collection costs including attorneys’ fees associated with recovering payment owed hereunder.
3. LabFinder is acting solely as an intermediary facilitating the scheduling of services or ordering of products provided by third party providers, through technological means.
4. LabFinder has no responsibility whatsoever for any claims against or adverse effect on the Provider or its professionals under this self-pay arrangement. This includes, without limitation, if the Provider or its professionals are in-network with the particular insurance or other payor program or plan (including private and governmental) with which the Consumer participates as a beneficiary. Similarly, we have no responsibility to the Consumer if there is an alternative provider whose qualifications or specialties or participation match those required to treat the individual Consumer on an in-network and otherwise participating provider basis.
5. LabFinder makes no assurance at all as to whether or not the agreed upon pricing for the Service is the best possible price or is competitive or fair at the time of the rendering of the Service, and the Consumer is advised that he/she may possibly pay less (taking into account any co-payment and deductible, or co-insurance obligation, as applicable) if he/she sought such service through his/her own insurance coverage or other payor program or plan (including governmental).
6. LabFinder will not be performing any claims adjustment services or auditing the performance of Services. LabFinder will not be pursuing any collection against the Consumer on behalf of Provider. Payments are due in advance through online mechanisms arranged for by LabFinder. LabFinder will not be handling any disputes between the Consumer and the Provider, whether regarding payment, the provision of the Service or otherwise. The Consumer and Provider are solely responsible for ensuring/seeking/settling as between themselves any issues and disputes including those relating to the provision of a Service and quality of care. BOTH OF SUCH PARTIES AGREE TO COMPLY WITH THE ABOVE CANCELLATION AND REFUND POLICIES.
7. Each of Consumer and Provider hereby expressly acknowledge and agree that we are: (i) a technology development and online website/app company; (ii) not an insurance company, benefit plan or third party administrator and are not determining any Consumer’s eligibility to receive benefits under any third party payor program or plan (private or governmental); and (iii) for purposes of the Employee Retirement Income Security Act of 1974 (“ERISA”) or any equivalent or similar other state or federal laws/regulations that may be applicable, we shall not be deemed the “administrator” or “named fiduciary” of any benefit program or plan.
8. Consumers shall look solely to Provider for refunds owed of all or any portion of the Service Charge in all instances and circumstances, but subject to the terms hereof.
9. LabFinder HAS NO LIABILITY WHATSOVER FOR ANY INJURY, DAMAGE, DEATH, LOSS, ACCIDENT OR DELAY DUE TO ANY FAULT, ACT OF NEGLIGENCE, OMISSION OR DEFAULT OF THE CONTRACTING PROVIDER OR CONSUMER. IN NO EVENT SHALL LabFinder BE LIABLE TO EITHER CONSUMER OR PROVIDER FOR LOSS OF GOODWILL, OR FOR SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL OR PUNITIVE DAMAGES ARISING OUT OF OR RELATING TO THIS AGREEMENT, THE PRICING AGREED UPON AND THE SERVICES SOUGHT OR RENDERED, REGARDLESS OF WHETHER SUCH CLAIM ARISES IN TORT OR IN CONTRACT.
10. Each of Consumer and Provider hereby agree that they are subject to the Terms of Use they agreed to upon registering or activating their LabFinder account. The Terms of Use for Consumers are accessible here, and Providers can access their Terms of Use here, which terms are hereby deemed incorporated herein as if fully a part hereof and supplement hereto. Each party represents and warrants it has reviewed and agreed to such Terms of Use, respectively.
11. We may assign this Agreement to any successor to our business or assets to which this Agreement relates.
12. We are deemed a party to this Agreement for purposes of enforcing our rights, the agreements and protections favoring us herein. If an applicable jurisdiction determines we are not a direct party, then we shall instead be deemed a third party beneficiary of this Agreement for the same purposes.
13. Each party represents and warrants that it is duly authorized and has full power, capacity and authority to accept this Agreement on behalf of such party, including the above named Consumer or Provider. If the person agreeing hereto is the legal representative of the Consumer, such legal representative represents and warrants to the parties hereto that he/she/it is fully authorized to enter into this Agreement on behalf of the Consumer and such legal representative hereby further becomes a party hereto and fully bound hereby as if the Consumer party.
14. This Agreement as it pertains to Service rendered to Consumer by Provider shall be governed by the laws of the State in which the applicable Provider is rendering the Service, without regard to the conflicts of law provisions thereof. However, the governing law, jurisdiction and venue for any claims with respect to and involving LabFinder shall be in accordance with the provisions of the parties’ respective Terms of Use.
15. By clicking below, entering into this agreement and otherwise using the LabFinder website/app, each of Consumer and Provider accept these terms and conditions as a fully enforceable agreement.

By your acceptance below, you acknowledge that you have read and understand this notice.
Created on Date Time : [DATE_TIMESTAMP]

Electronically Signed By:
[PATIENT_NAME]
[DATE_TIMESTAMP]

Provider:

Trak Fertility
[DATE_CONFIRMED]

LabFinder LLC.
[DATE_CONFIRMED]