ModoGen Medical

 TERMS AND CONDITIONS

Updated as of: 06-15-2024

​Welcome to ModoGen Medical. By accessing or using our services, you agree to be bound by these Terms and Conditions. These terms and conditions of use (“Terms”) govern your use of our online interfaces and properties (e.g., websites and social media accounts) owned and controlled by Members Only MedSpa, LLC, doing business as “ModoGen Medical”, (the “Company”), including the www.modogen.com website (the “Site”) as well as the services (“Services”) available to clients of ModoGen Medical. The professional services are referred to in this Terms of Use as the “Services”. The terms “client”, “patient”, “you” and “your” means you, your dependent(s) if any, and any other person accessing your ModoGen Medical information.

Your acceptance of, and compliance with, these Terms is a condition to your use of the Site and Services. By clicking “accept” or by agreeing to undergo treatment with ModoGen Medical, you acknowledge that you have read, understood, and accepted all terms and conditions contained within these Terms and the Notice of Privacy Practices. Please read them carefully before using our services. If you do not agree to these terms, please do not use our services and exit this site immediately.

I. Notice of Privacy Practices

You agree that information provided by you in connection with the Services and Site shall be governed by the Notice of Privacy Practices, which is hereby incorporated and made a part of this Agreement.

II. Services Provided

ModoGen Medical offers a range of medical services including:

• Weight loss through the use of prescription medication to reduce appetite and cravings.
• Joint therapy using stem cell, PRP, and alpha-2-macroglobulin injections along with Extracorporeal Shockwave Therapy (ESWT).
• Skin rejuvenation using medical grade medspa devices for the treatment of fine lines and wrinkles, hyperpigmentation, fat reduction, muscle toning, hair removal, and acne.

ModoGen Medical makes no guarantees or warranties as to the effectiveness of any treatment provided.

III. Initial Assessment Notice

You will be attended to by a medical professional who will perform an appropriate medical assessment for the condition you are wishing to treat, check your general medical conditions, conduct a medical history, inquire about any medications you are presently taking, and discuss with you the specific concern(s) for which you have contacted the Company. Please be as specific as possible in your responses. Our staff needs accurate information in order to ensure safe recommendations for your treatments. ModoGen Medical reserves the right to deny treatment if a patient is deemed unsuitable for any reason, based on medical evaluation. The Client agrees to immediately notify ModoGen Medical of any changes to his or her medical history or medication usage once they begin a treatment program.

If your questions or concerns are outside the scope of practice of the Company, you will be recommended to seek evaluation with a local medical provider. The information and services provided by ModoGen Medical are not intended to be a substitute for general medical advice, diagnosis, or treatment beyond the scope of the treatments the Company provides. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding general medical conditions or conditions outside the scope of ModoGen Medical’s practice. 

In an emergency situation, the staff members of the Company reserve the right to contact local emergency response personnel to have you evaluated in person. The Company will not be responsible for any resulting fees.

IV. Billing and Payment Agreement

​You agree to provide, and to keep on record, valid credit card information for automatic and incidental payments of services and items; including, but not limited to, the following:

1. Activation fee(s)
2. Program fee
3. Purchased products
4. Monthly recurring charges
5. Monthly membership fees (if applicable)
6. Processing fees
7. Taxes

 Monthly fees will be automatically charged to the credit card you have provided. The standard billing cycle is every 1st of the month and monthly memberships are billed in advance on this day. Clients who commit to a month-to-month program agree to automatic withdrawals for the agreed-upon monthly amount from the credit or debit card provided.

 Products and additional services/treatments purchased will be charged to the credit card on file immediately upon confirmation of the purchase by the Client.

Some treatments may require additional fees to cover the cost of non-reusable items or supplies. Any additional fees will be discussed prior to the treatment and must be paid for prior to the start of treatment. Failure to do so may result in canceling or rescheduling of treatment.

Non-recurring payments are due at the time of service unless other arrangements have been made. Except for promotional offers, the Company will not provide treatment without payment. ModoGen Medical accepts various forms of payment. Please inquire with our office for specific details. 

Financing

Some treatment plans may qualify for third party financing. ModoGen Medical is happy to direct Clients towards appropriate financing options to assist in paying for their treatment program. ModoGen Medical does NOT, however, accept liability for any agreements, terms, communication, payment or interactions between the Client and the financing company. Any disputes or disagreements between the Client and their financing company must be taken up with the financing company. 

Medical Insurance Policy

ModoGen Medical does not file claims with any insurance carriers for the payment of services or medication prescribed. Furthermore, the Company will not file with individual insurance companies and Clients cannot appeal if any of these parties are not billed.

V. Appointment Etiquette

Children

ModoGen Medical is a medical facility. For the safety of your children, please arrange to leave them in the care of another person during your appointment. If you must bring your child, no children under the age of 18 may be left unattended and may not accompany you in treatments as this could pose a risk to you, your child, or a staff member.

Treatment Providers

ModoGen Medical will make every attempt to pair you with the Treatment Provider of your choice. However, due to illness, time off, training qualification or other unforeseen circumstances, the Company may not always be able to meet your request.

Late Arrival

A Client should make every attempt to arrive at their appointment on time. In the event that a Client arrives late, ModoGen Medical will try to accommodate to the best of its ability but reserves the right to reschedule, cancel or shorten the Client’s appointment as a consideration to the other Clientele. Any shortened appointments are still charged at full value. Late rescheduled appointments may result in late cancellation fees or forfeiture of that appointment and treatment.

Late Cancellation or Missed Appointments

Out of courtesy to other ModoGen Clients, ModoGen Medical reserves the right to assess late cancellation fees for missed appointments or appointments canceled within 24 hours of the appointment time.

VI. Weight Loss Treatments

Weight Loss Services

To provide a comprehensive approach to weight loss, all weight loss packages include a consultation with a medical professional, provider-required blood draw and labs, medical monitoring, and prescription medication designed to reduce appetite and cravings. 

Weight Loss Program Term

All weight loss programs are month-to-month commitments; however discounts may be provided for those who commit to and purchase multiple months upfront. 

Weight Loss Cancellation Policy and Agreement

A Client may choose to terminate their program at any time but will not be refunded for current or previous months or for medication that has already been submitted to a pharmacy to be filled. If the Client received a discount for purchasing multiple months upfront, this discount will be deducted from any refund provided if the member did not fulfill the duration of that commitment. 

Example: A Client received a 10% discount for purchasing 6 months of the weight loss program upfront. 3.5 months later, the Client cancels their program. The Client would be refunded for 2 months of the weight loss program less the 10% discount they received. 

All weight loss program cancellations take effect on the first day of the following billing cycle. 

2-Month Minimum

Once medication has been ordered, due to the cost and quantity of the medication provided, no refunds will be given for the first two months of weight loss treatment, regardless of the reason. 

Auto Renewal

Once a Client has reached the completion of a predefined weight loss program duration, the Client will be automatically enrolled into a month-to-month weight loss program and will be charged the standard monthly fee for this program at the next billing cycle. The Client may elect to select a different Program so long as they are medically qualified to do so or may opt out of automatic enrollment by contacting a ModoGen Care Coordinator or Manager.

Right to Terminate

ModoGen Medical has the right to terminate a Client’s weight loss program if it believes it is no longer safe for the Client to continue or if circumstances arise that would prevent the good practice of medicine. These circumstances include:

• The Client develops or learns of a medical condition that would be a contraindication to treatment
• Side effects are too severe or dangerous 
• Blood draw values are out of normal range
• The Client fails to obtain necessary follow-up blood draws
• The Client is non-compliant with the medication 
• The Client fails to attend follow-up appointments
• The Client fails to make payment for services

VII. Joint Therapy

Joint Therapy Services

To provide a comprehensive approach to joint care, ModoGen provides a variety of treatment modalities designed to relieve pain and restore mobility in affected joints. These treatments include platelet-rich-plasma (PRP) injections, stem cell therapy, alpha-2-macroglobulin (A2M) injections and extracorporeal shockwave therapy along with medical monitoring throughout the duration of the treatment plan.

The Client acknowledges that some or all of the treatments provided are not approved by the Federal Drug Administration for the intended purpose of therapy. As such, the Client understands that ModoGen Medical makes no guarantees or warranties as to the effectiveness of any treatment provided.

Joint Therapy Term

Joint therapy requires a series of visits with ModoGen Medical staff at specific time intervals for treatment and follow up therapy in the months succeeding the start of treatment. The Client should expect joint therapy treatment to take 6 or more weeks not including appropriate time needed for recovery and healing. For maximal results, the Client is highly encouraged to attend all scheduled treatments and follow up appointments. Failure to comply with these directions may result in termination of the program and/or forfeiture of payment.

Joint Therapy Cancellation Policy and Agreement

ModoGen Medical does not offer refunds for treatment already provided. In the event that a Client must cease the joint therapy program prior to its completion, a partial refund will only be given in the following circumstances:

• Injury of the specified joint or part of body that affects the joint that would prevent safe continuation or healing (requires documentation from a medical provider)
• Medical disqualification (requires documentation from a medical provider)
• A Modogen Medical provider recommends cessation of treatment (see below)
• Death
• Cases in which the Company is at fault. 

Right to Terminate

ModoGen Medical has the right to terminate a Client’s joint therapy program if it believes it is no longer safe for the Client to continue or if circumstances arise that would prevent the good practice of medicine. These circumstances include:

• The Client develops or learns of a medical condition that would be a contraindication to treatment
• Side effects are too severe or dangerous 
• The Client is non-compliant with pre- or post-care instructions
• The Client fails to attend follow-up appointments
• The Client fails to make payment for services

In the event that a Client qualifies for a partial refund, the amount of the refund given is at the complete discretion of the Company. Medical supplies already used and staff Medical Provider time will be taken into consideration in determining the appropriate reimbursement amount. Additionally, a cancellation fee of $500 will be deducted from the refund amount.

VIII. Medical Spa Treatments

Medical Spa Services

ModoGen Medical provides a wide variety of medical grade skin and body treatments designed to treat fine lines and wrinkles, sunspots/dark spots/hyperpigmentation, acne, oily or dull/dry skin, unwanted hair, unwanted/stubborn fat, and others.

Prior to receiving any Medical Spa Service, a Client must receive a skin and body assessment to determine the appropriateness and safety of all treatments. Clients who refuse this assessment will not be treated. Medical staff will not perform treatments for which the Client is not medically approved for.

Some Medical Spa Treatments require a medical wait time between treatments. These wait periods are put in place as a safety measure for the Client and cannot be waived except by a ModoGen Medical Provider.

Medical Spa Packages

ModoGen Medical provides medical spa packages that are specifically designed to target particular conditions. These packages contain a set number and type of treatments. Substitutions to treatments provided within the package may or may not be accepted and must be approved by a ModoGen Care Coordinator. ModoGen retains full discretion of treatment substitutions. Approved substitutions retain the same value as the original treatment. No refunds or credits will be provided for a treatment substitution. 

All treatments contained within a Medical Spa package must be used by the designated client and cannot be gifted to another individual. 

Medical Spa Term

Clients have up to 1 calendar year to utilize all treatments provided in their designated package. Any treatments not utilized after their expiration date will be forfeited and will not be refunded.

Medical Spa Cancellation Policy and Agreement

Clients should prepare for the time commitment needed to complete a medical spa package. In the event that a Client is unable to complete a medical spa package and qualifies for a partial refund, the amount of the refund given is at the complete discretion of the Company. Medical supplies already used and staff and Medical Provider time will be taken into consideration in determining the appropriate reimbursement amount. Additionally, a cancellation fee of $250 will be deducted from the reimbursement amount.

ModoGen Medical does not offer refunds on services rendered even when the Client is disappointed in the result or unhappy with the outcome. 

IX. Medical Spa Membership (no longer available)

Prior to June 30th, 2024, ModoGen Medical, operating as “Members Only MedSpa” offered membership plans for both medical spa services as well as weight loss services. ModoGen Medical no longer offers new memberships but will continue to honor any existing memberships until further notice. Members who cancel their membership will not be able to renew their membership at a later date and will not be able to change to a different membership level. They may choose to receive new or other services offered by ModoGen Medical.

Trial Membership

Once a prospective Member has signed up to receive their first treatment or consultation, they are automatically assigned a Trial Membership. This Membership level establishes the prospective Member’s demographic profile and allows them to schedule a medical spa treatment of any type except for BOTOX or a weight loss consultation prior to activating a formal membership. The prospective Member must undergo a Medical Assessment by a trained ModoGen Medical staff member prior to receiving any treatments. 

MedSpa Memberships

A MedSpa Membership allows a Member to schedule any treatment he or she desires but does not include the use of prescription medication. There are different membership levels that vary based on cost of monthly membership and on the number of treatments a Member is authorized to schedule within a given month. The membership details are as follows:

• • Select 1 Membership (formally known as a Limited Membership) - a Member may book up to one treatment per month from any of the treatments available and may purchase additional treatments as needed. Additionally, the Member may book treatments up to two months in advance.
  • Select 2 Membership - a Member may book up to two treatments per month from any of the treatments available and may purchase additional treatments as needed. Additionally, the Member may book treatments up to two months in advance.
  • Select 4 Membership - a Member may book up to four treatments per month from any of the treatments available and may purchase additional treatments as needed. Additionally, the Member may book treatments up to two months in advance.
  • Select 6 Membership - a Member may book up to six treatments per month from any of the treatments available and may purchase additional treatments as needed. Additionally, the Member may book treatments up to two months in advance.
  • Select 8 Membership - a Member may book up to eight treatments per month from any of the treatments available and may purchase additional treatments as needed. Additionally, the Member may book treatments up to two months in advance.
  • Unlimited Membership - see section below

• Botox-Only Membership - a Member receives 50 free units of Botox and may utilize these units at a time of their choosing. The Member will have up to one year to use all of their units at which point, any remaining units will be forfeited. 

MedSpa Membership Appointment Limits/Roll-Over Credits

Some membership levels, as described above, have a set limit on the number of appointments a Member can schedule within a given month. Members who wish to schedule appointments in addition to this limitation can do so at an additional cost to the Member. This additional cost must be paid for at the time of scheduling the additional appointment.

If a Member does not utilize all appointments provided by their Membership level in a given month, all unused appointments will roll over into the subsequent month. These credits will remain in the Member’s account until they are used for up to two months thereafter. In the event that a Member downgraded their membership within the previous 2 months, they may still rollover the total number of unused appointments from that membership. Example: A member downgraded from a Select 6 membership to a Select 2 membership 1 month ago. If a member had 6 appointments to roll over from this Select 6 membership, they would be able to roll over all 6 of their appointments even though they downgraded to a lower tier membership. 

BOTOX appointments and Medical Evaluations do not count towards a Member’s appointment limits. If a Member has reached his or her monthly limit of appointments, he or she may schedule a BOTOX appointment or Medical Evaluation without being required to pay for an additional appointment. 

Canceling Appointments/Member Credits

A Member may cancel an appointment at any time up to the start of the appointment time through the MO Portal or by calling the office. In the event that the Member purchased a microneedle cartridge when scheduling a microneedle appointment the Member’s account will be credited for this purchase upon cancellation. This Member will then be able to use the microneedle cartridge credit at a subsequent microneedle appointment. The Member will not be refunded for the purchase of the microneedle cartridge. 

In the event that a Member cancels their membership, any remaining roll-over credits will be forfeited at the completion of their membership date. A Member may NOT use roll over credits after their membership has ended. Roll-over credits are non-refundable.

In the event that the Member purchased an extra appointment, the Member’s account will be credited for this purchase if the Member cancels this appointment prior to the start of the appointment time. This Member will then be able to use the extra appointment credit whenever one is needed in the future. The Member will not be refunded for the purchase of the extra appointment. 

Credits may only be used for their original purposes and cannot be transferred to other Members, converted into cash or used towards credits in any way other than for their original purpose. A credit of one kind cannot be used as a substitute for another purchase or to reduce the cost of a monthly membership fee. 

Member credits do not expire. However, if a Member cancels his or her membership, any credits to the Member’s account will be forfeited and will not be refunded. 

Unlimited Membership

Unlimited Membership refers to the potentially unlimited number of treatments Members can schedule within a given month. Members must note; however, that treatments may be limited due to medical considerations of the individual as indicated on their Medical Assessment or updated medical history such as skin type, skin condition(s), recommendations by their primary care physician or other reasons that would affect a Members ability to receive certain treatments. Additionally, treatments of the same body parts have recommended safe medical wait times that Members and medical staff  must abide by. 

Unlimited Members may schedule any two appointments at a time per calendar month with the exception of BOTOX appointments or Medical Evaluations as discussed above. If a Member has scheduled two appointments, one appointment must be completed prior to scheduling the next appointment. This controlled system is designed to create a fair scheduling practice so all Members may be given the opportunity to book appointments each month. The Company reserves the right to control the scheduling system and to hold certain appointment dates and/or times with or without notice and for reasons including, but not limited to, the following:

• Training
• Equipment maintenance
• Company events
• Holidays
• Promotions

Changing MedSpa Membership Levels

Legacy MedSpa Memberships can no longer be upgraded or downgraded to other Membership plans.

MedSpa Monthly Membership Cancellation Policy and Agreement

This Agreement will commence on the date the Member activates membership. Member acknowledges review of the Member Billing Practices (“Billing”) and agrees to all of its terms. The Company shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination, with or without notice. 

If a Member wishes to terminate his or her membership, the Member’s termination request must be submitted through the MO Portal or communicated in writing to a Care Coordinator or the VP of Operations. Upon submitting the termination request, the Member will continue to receive services in accordance with the agreement and membership level through the end of that billing cycle. The Member’s membership will then terminate automatically at the end of the billing cycle and all treatments scheduled beyond the termination date will automatically be canceled. In the event of termination of membership, any and all costs associated with the past and all serviceable months, including the month during which termination is finalized will not be refunded. In the event the Member is in arrears of payment or otherwise in default of this Agreement, all payments due hereunder shall be immediately due and payable. The Company shall be allowed to immediately collect all sums from the Member and may terminate providing further services to the Member.

All membership levels receive discounted in-store products and may purchase additional medspa treatments a la carte.

​

X. Medication Prescriptions

ModoGen Medical may prescribe specific medication or pharmacologic products for the treatment of certain conditions. Company providers reserve the right to deny care for actual or potential misuse of prescribed medications. There is no guarantee a prescription will be written. If a Provider does prescribe a medication, he/she will limit supply based upon state regulations.

 You agree that any prescriptions that you acquire will be solely for your personal use. You agree to thoroughly read through all provided information and labels regarding your medication and to contact a physician or pharmacist if you have any questions regarding the prescription. 

XI. Communication Consent

Notwithstanding any current or prior election to opt in or opt out of receiving automated voice message calls and/or use of an automatic dialing device, text messages and/or emails from the Company, our partners, subcontractors, or any and all other companies that we may have to transfer your account to at any telephone number or email address that you have provided us or that we have otherwise obtained, which could result in charges to you. We may place such calls, texts, or emails to include, but not limited to:

1. Notify you regarding upcoming appointments
2. Provide confirmations and reminders
3. Follow up and provide information pre and post visits
4. Provide home healthcare instructions and advice
5. Troubleshoot problems with your account
6. Resolve a dispute
7. Collect a debt
8. Services and promotional offers
9. As otherwise necessary to service your account or enforce this admissions agreement, our policies, applicable law, or any other agreement we may have with you.

 The ways in which you may provide us a telephone number or email address include, but are not limited to, providing the information at account opening, adding the information to your account at a later time, providing it to one of our employees, providing it to our partners, subcontractors, or any and all other companies that we may have to transfer your account to, or by contacting us or our partners, subcontractors, or any and all other companies that we may have to transfer your account to from that phone number or email address. If a telephone number provided to us is a mobile telephone number, you consent to receive SMS or text messages at that number. Standard telephone minute and text charges may apply if we contact you.

 You agree that all agreements and consents can be signed electronically and all notices, disclosures, and other communications that we provide to you electronically satisfy any legal requirement that such notices and other communications be in writing. You may revoke this express consent at any time by terminating your membership.

XII. Member Records

You authorize ModoGen Medical to maintain the Client records and information for services provided to you.

Client Health and Demographic Information

You represent that you are acting on behalf of yourself and for your own aesthetic treatment. You agree that any information provided to a ModoGen Medical nurse or staff member, whether written or spoken, is accurate and complete to the best of your knowledge. You understand that any misrepresentation may lead to inappropriate treatments, over- or under- treating, potentially dangerous side effects, violations of the law or other unintended repercussions. You agree to immediately notify the Company if your health condition, medical history, medication, or any other information previously presented to the Company changes or was incorrectly reported.

 You warrant that you are at least 18 years of age. The Company operates under state and federal regulations. The Site and/or Services provided by the Company are limited exclusively to its current and prospective Clients.

NOTICE OF PRIVACY PRACTICES

Members Only MedSpa, LLC, doing business as ModoGen Medical (the “Company”) is committed to respecting the privacy of our Members and maintaining the confidentiality of their protected health information. When you consent to treatment at ModoGen Medical, you consent to the use of your information as outlined in our Notice of Privacy Practices. If we decide to change our Notice, such changes will be posted on our website: www.modogen.com. You may visit our website and browse without giving us any personal information.

 If you have any questions or comments regarding our Privacy Policies or the security of your information, contact ModoGen Medical and ask for the Manager.

• Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

You may request a paper copy of this Notice of Privacy Practices

• Our Pledge to You

ModoGen Medical creates a detailed record of the treatments and services you receive at our facilities. By law, we must keep this record private. We must also provide this summary of our legal duties and privacy practices as well as follow them. Our policies apply to all of the records of your treatments that the Company maintains.

• Who Will Follow These Privacy Practices

ModoGen medical provides treatments and services in partnership with other agencies. These privacy practices will be followed by:

• Any staff member who treats you at any of our locations
• All board members, employees, staff, and volunteers of our organization
• All members of our medical staff and allied health practitioners
• Any business associate or partner who agrees to maintain your privacy

• Some Ways Your Medical Record May Be Used or Shared

We may use or share medical information about you:

• To conduct, plan and direct your treatment and follow-up among the multiple treatment providers who may be involved in your treatment directly and indirectly

• For treatment, such as a referral to a specialist or other health care agency
• For health care functions, such as to improve our services
• For regulatory agencies, such as during an audit or survey of our facilities
• With those whom you designate to be involved in your care
• In an emergency or disaster so that your family or friends can be told where you are and how you are

• When required for public health reports, abuse or neglect reports, or funeral arrangements 
• When required by law such as a request from law enforcement or a legal order
• When required by military authorities if you are a member of the military or a veteran
• For national security and intelligence activities, or for the protection of the President or other Government officials

• Other Ways That Information About You May Be Used

Unless you tell us not to, we may use information that we have about you to:

• Remind you of an appointment
• Recommend possible treatment options
• Tell you about promotions and services

• Uses and Disclosures That Require Your Authorization

In any other situation not covered by this notice we will get your written authorization before using or sharing your health information. You may revoke any authorization in writing.

• Your Rights Regarding Medical Information About You

In most cases, you may review and obtain a copy of your medical record. There may be a fee for the cost to copy and mail it. Your request must specify how or where you wish to receive your medical record. We will honor all reasonable requests.

You may ask us to correct your record if you think that it is incorrect or that key information is missing. You must put your request in writing and state the reason for your request. We cannot revise your record if the information was not created by us; or is not part of the medical record we maintain; or is not part of the record that you can review or copy or if we find out that the record is accurate.

You may get a list of when and whom we gave your medical information. Such a list would not include the permitted disclosures outlined within this notice. Your written request for such a list must state a time period; it must start after April 14, 2003, and be within six years of the current date. The first list in a 12-month period is free; other requests will include a fee for our cost to produce the list. We will inform you of the cost before we process your request.

You may ask that we communicate medical information about you in a confidential way, such as sending mail to an address other than your home. We will honor all reasonable requests. Our waiting areas and some of our treatment areas are shared with other Members. Please tell us if you object to this type of waiting or treatment areas. We will do our best to accommodate your request for privacy.

You may ask that we not use or disclose a certain part of your information as allowed by this notice unless you sign a consent form to release the information. By law, we do not have to accept such a request, but we will seriously consider it and inform you of our decision. Your request must tell us what specific information you want to limit and to whom the limits apply. You may make any of these requests in writing to the Company Privacy Officer.

• Changes to the Company’s Privacy Notice

We may change our privacy policies at any time. Changes will apply to prior and new medical information. Before we make major changes in our policies, we will change our Notice of Privacy Practice and post the new notice on our website. You can get a copy of the current privacy notice at any time. The effective date is listed just below the title.

• Complaints and Appeals

You may contact the Company Privacy Officer if:

• You think that your privacy rights may have been violated 
• You disagree with our decision about access to your records 
• You disagree with our decision not to correct your record

 We will not punish you in any way for filing a complaint. You may also send a written complaint to the U.S. Department of Health and Human Services’ Office of Civil Rights

Privacy Officer
Members Only MedSpa, LLC
320 Ward Ave Suite 101
Honolulu, HI 96814

 Office of Civil Rights
US Department of Health and Human Services 1961 Stout Street #1428
Denver, CO 80294 (Cannot phone)