Managed Service Agreement 6

GLOBAL HEALTH MANAGEMENT CORP. – MANAGED SERVICE AGREEMENT

NO PRESCRIPTIONS(S) WILL BE FILLED UNTIL A SIGNED AND DATED COPY OF THIS DOCUMENT AND A COMPLETED CUSTOMER HEALTH PROFILE HAVE BEEN RECEIVED BY GHM (DEFINED BELOW)

I, as the undersigned, being over the age of 21, hereby enter into this agreement (the “Agreement”) with GLOBAL HEALTH MANAGEMENT CORP. ("GHM"), of Suite 770, 2710 - 17 Ave S.E. Calgary, Alberta,
T2A 0P6, 1-866-266-9955 intending to be legally bound:

1.01      I am delivering this Agreement to GHM because I wish to place an order (“My Order”) for certain prescription and non-prescription drugs (“My Medications”), on the terms and conditions set out herein.
1.02      I hereby appoint GHM to be my patient representative. I am hereby instructing GHM to assist me in purchasing My Medications from a licensed outside of the USA (the "Pharmacy"), I entrust GHM and its staff to facilitate my contact with the Pharmacy and provide me with the services that permit me to purchase My Medications from the Pharmacy.
1.03      I understand that GHM is not a pharmacy. I have been advised that GHM is a health management company which operates a call centre to respond to my inquiries and provides the information technology framework to handle data entry and manage the processing of my order.
1.04      I have instructed GHM to take all steps necessary including the signing of any documents required to fulfill my order and then arranging to have the Pharmacy deliver My Medications by placing My Medications in the mail to me in the same manner as I could have done myself.
1.05      I confirm, acknowledge and agree that I want to purchase My Medications from, and have My Order filled by the Pharmacy and that I want GHM to act as my representative to assist me in completing the purchase of My Medications.
1.06      GHM will also track my refills for me and respond to any inquiries about the status of my order, shipping, billing and any other special arrangements that need to be made on my behalf, including facilitating communication with the dispensing pharmacists and coordinating communication between my primary care physician, the Canadian physician and the pharmacist involved in my care.
1.07      I acknowledge and confirm that I am purchasing My Medications from the Pharmacy and that My Medications will be shipped to me by the Pharmacy.
1.08      I specifically confirm, acknowledge and agree that title to My Medications passes to me from the Pharmacy when My Medications leave the dispensary at the Pharmacy, and that any and all agreements reached or contracts formed throughout the course of my purchase of My Medications are and shall be deemed to be made in the Province of Alberta, Canada and accordingly shall be governed by the laws of the Province of Alberta and the laws of Canada applicable to such contracts and agreements.
1.09      I specifically confirm, acknowledge and agree that any dispute that arises between me and GHM or the Pharmacy shall be governed by the laws of the Province of Alberta and the laws of Canada applicable to contracts formed in Alberta, and the Courts of the Province of Alberta shall have sole and exclusive jurisdiction over any such dispute.
1.10      I have been advised and fully understand that I will be receiving professional services in the Province of British Columbia and those are being arranged on my behalf by GHM. I have also been advised and fully understand that if I have any concerns about the products or services I am receiving from the Canadian Pharmacy I have the right to file a complaint with the College of Pharmacists of British Columbia and also have the right to bring legal action against the Pharmacy and Pharmacist(s) if I choose to do so.
1.11      The additional Terms and Conditions set out on Schedule A" hereto, (which Schedule is hereby incorporated herein by reference) form an integral part of this Agreement, and I acknowledge having read such terms and conditions and that I agree to them.

I HAVE READ AND UNDERSTOOD THE TERMS AND CONDITIONS SET OUT IN THIS AGREEMENT AND AGREE, ON BEHALF OF MYSELF, MY HEIRS, SUCCESSORS, ADMINISTRATORS AND ASSIGNS, TO BE BOUND BY THESE TERMS AND CONDITIONS.

Signed this____________ day of ____________, 2010.


Signature of Witness	Signature

Please print Witness name clearly	Please print name clearly

Schedule "A"
ADDITIONAL TERMS AND CONDITIONS

PART 1 - AUTHORIZATIONS AND CONSENTS
The authorizations, powers of representation and consents that I am providing herein to GLOBAL HEALTH MANAGEMENT CORP. (“GHM”) and the Canadian pharmacy which fills my order (the “Pharmacy”) commence on the date I sign this Agreement and will continue until I cancel them. I understand that I can cancel the consents and authorizations I have herein granted at any time.
1.1    I hereby authorize and appoint GHM as My representative and attorney for the limited purpose of taking all steps and signing all documents on my behalf necessary to obtain an Equivalent Prescription (defined below), to the same extent as I could do personally if I were present taking those steps and signing those documents myself. This authorization includes, but is not limited to: collecting Personal Information (defined below) about me; collecting similar information from My Doctor or pharmacist; and disclosing my Personal Information to GHM’s employees, agents, contractors, subcontractors, affiliates and service providers, including without limitation any Canadian Physician (defined below), the Pharmacy and any pharmacist being engaged on my behalf (collectively, “My Representatives”), as required, for the limited purpose of obtaining the Equivalent Prescription and for My Order to be filled.
1.2    In this Agreement, the term:
(a)   “Equivalent Prescription” means a prescription or equivalent authorization or approval that (in accordance with the laws of the Province of Alberta and Canada) is the equivalent of My Prescription; and
(b)   “Personal Information” means personal health and medical information about me (including, without limitation, my medical history and drug history), my contact and demographic information (including, without limitation, my full name, address and phone number) and payment information.
1.3    Without limiting anything else herein, I hereby provide my consent to allow a physician retained by GHM on my behalf (the "Canadian Physician”), licensed to practice in Canada, to obtain Personal Information and other necessary documentation from My Doctor. This Canadian Physician will be a duly licensed physician in one of the Provinces or Territories of Canada
1.4    I further consent to each Canadian Physician, the Pharmacy and My Doctor being able to contact one another to discuss my Personal Information, as it pertains to the prescribing of My Medications. I understand that the reason for this consent is to provide each Canadian Physician and the dispensing Pharmacy with the full opportunity to conduct an independent analysis of whether My Prescription is appropriate, and discuss any potential medical complications that might arise. I further understand that my medical information will not be used for any other reason, and will be kept in strict confidence. I further confirm and acknowledge that I am under the ongoing care of My Doctor, and I agree to regularly visit My Doctor and to promptly advise the Canadian Physician and GHM of any changes to my medical condition or prescriptions. It is clearly understood that I am not seeking medical treatment or service of any kind from any Canadian Physician, GHM or My Representatives with regard to any medical advice, professional advice or treatment of any kind whatsoever. I have relied only on My Doctor in respect of My Prescription.
1.5    I hereby specifically acknowledge that I am aware that GHM will be transmitting my Personal Information by electronic means (for example fax, or secure internet) to My Representatives and the Canadian Physician. I understand that the use of electronic means will enhance the efficiency and timeliness of processing My Order. I also understand that GHM. as a custodian of my Personal Information, will take all appropriate precautions to protect my Personal Information from improper disclosure or use. I hereby consent to GHM's transmission of my Personal Information by electronic means to My Representatives and the Canadian Physician.
1.6    If I was directed to GHM‘s services through an intermediary (for example, a Pharmacy Benefit Manager, Health Management Organization or other service provider), I hereby authorize GHM to release the following data to such an intermediary: a numerical identifier indicating that I was referred from that source; and financial information that will permit the processing of any claims on my behalf. It is my understanding that all such intermediaries will provide confidentiality covenants to GHM whereby they agree to hold any such information in strictest confidence and to abide by the privacy policies of GHM relating to the protection of my Personal Information. I specifically consent to the transmission of the forgoing information to such intermediaries by electronic means.
1.7    I hereby specifically authorize and appoint GHM and My Representatives as my Representatives and attorneys for the purpose of taking all steps and signing all documents on my behalf necessary to package or repackage My Medications and to arrange delivery of them to me, to the same extent as I could do if I were personally present taking those steps and signing those documents myself.
1.8    I confirm, acknowledge and agree that I initiated a consultation with GHM and that GHM is not located in the United States.

PART 2 - DISCLOSURE AND REPRESENTATIONS
2.1    I hereby represent and confirm to GHM, and to each of its affiliates, associates, related companies, subsidiaries and parent company and each of their respective directors, officers, shareholders, employees, contractors, subcontractors, successors and assigns and to My Agents that:
(a)   My Medications were prescribed by a doctor (“My Doctor”) licensed to practice medicine in the country, state or other applicable jurisdiction in which I reside, or where I sought treatment;
(b)   the prescription for My Medications (“My Prescription”) was lawfully obtained by me from My Doctor;
(c)   I will use My Medications strictly according to the instructions provided by My Doctor, as the person for whom they were prescribed. I will not allow anyone else to use My Medications;
(d)   I can make my own medical decisions according to the laws of the place where I reside;
(e)   My Prescription has not been altered in any way, nor has it been filled prior to submission to GHM. I agree to immediately destroy all copies of My Prescription once it has been filled;
(f)   I am not seeking or relying on any medical information, advice or approval from GHM or My Representatives, and I have consulted a qualified physician licensed in the jurisdiction where I obtained My Prescription within the last year;
(g)   I will immediately contact My Doctor in the event I suffer any unexpected side effects from any of My Medications;
(h)   I understand that it is my responsibility to have regular physical examinations by my primary licensed physician that is responsible for my care, including all suggested testing, to ensure that I have no medical conditions or problems which would contraindicate me taking My Medications; and
(i)   I acknowledge that GHM and My Representatives have relied and will continue to rely on the information and documentation that I am providing to them (including this Agreement, My Order, My Prescription and my Customer Health Profile) and I represent and confirm that I have fully and truthfully disclosed all pertinent information and documentation to GHM. I agree to notify GHM of any changes to my physical or medical condition by providing an updated Customer Health Profile. I understand that if I have provided incorrect or incomplete information to My Doctor or GHM or My Representatives, medication could be prescribed and dispensed which is harmful to my health.

PART 3 - PURCHASE AND SALE TERMS
GHM will charge my credit card for the entire fee for services provided to me and I direct GHM to pay the dispensing pharmacy, the Canadian physician and any associated administration costs for the products and services I will receive. The price of the medication and all shipping charges will be set based on the day My Order is processed and all other documentation (including the Equivalent Prescription) necessary to enable the Pharmacy to fill My Prescription has been received. In the event my payment is not authorized, GHM has the right to cancel My Order and attempt to provide me with notice of such cancellation.
3.1    I confirm, acknowledge and agree that:
(a)   My Medications which are being dispensed by the Pharmacy will be packaged in child protected packaging, unless I request otherwise on my Customer Health Profile;
(b)   GHM and My Representatives are entitled to substitute a brand name prescription drug with a generic prescription drug, where available, unless My Doctor indicates that there be "no substitution";
(c)   once purchased and shipped, no medications may be returned or exchanged;
(d)   GHM and My Representatives reserve the right to refuse to assist me in obtaining My Order or any other order in their sole discretion, in which event I will be entitled to a refund for monies paid for such order;
(e)   neither GHM nor My Representatives provide their agency or attorney services as a substitute for healthcare or the advice of my primary care physician; and
(f)   neither GHM nor My Agents will exchange medications or return any monies paid once an order is filled, unless the medications provided to me by the Pharmacy do not correspond with My Prescription.

3.2    I SPECIFICALLY CONFIRM, ACKNOWLEDGE AND AGREE THAT EACH AND EVERY ONE OF THESE TERMS AND CONDITIONS, WITHOUT LIMITATION, WILL AUTOMATICALLY, AND WITHOUT FURTHER ACTION BY ME OR GHM, APPLY TO AND GOVERN ANY FUTURE ORDERS BY ME OF MEDICATIONS FROM GHM, UNLESS I SPECIFICALLY INDICATE OTHERWISE AT THE TIME OF ORDERING SUCH MEDICATIONS. WITHOUT LIMITING THE FOREGOING, EACH AUTHORIZATION AND CONSENT PROVIDED BY ME IN THIS AGREEMENT WILL CONTINUE UNTIL I CANCEL SUCH AUTHORIZATION OR CONSENT (WHICH I CAN DO AT ANY TIME).