Terms & Conditions & Privacy Practices

Concierge Membership Terms

1. Exclusivity of Membership: Only Members who are specified and paid in the Agreement will be qualified for privileges within our concierge program. This Agreement, and any of the rights Members may have under it, may not be assigned or transferred by Member unless stated in contract.

2. Fees: In exchange for the benefits and services expressed herein, the Member agrees to pay MODO Mobile Doctor the fee as set forth in the payment schedule page. This fee is payable upon Implementation of the Agreement and herein payments for the services provided to the member throughout the term of this Agreement. Additionally, standard fees may apply for after hours (10pm HST until 8am HST) visits, whether they are done via housecall, office visit, or telehealth. All rates are subject to change without notice.

3. Contract Terms: The terms of this contract will be for one calendar year beginning on the date that the contract is signed. This will automatically renew annually unless either party notifies the other in writing at least three days from the renewal date. By signing this Agreement you permit MODO Mobile Doctor the right to automatically charge your credit card when your membership is due for the monthly or annual renewal. You will receive one email notifying you of this charge. MODO Mobile Doctor reserves the right to terminate this Agreement as necessary in its sole discretion at any time, in which event it will return a prorated portion of the annual fee to participants.

4. Interactions: The membership grants Members access to our MODO Mobile team or said other designated physicians and healthcare providers via email, text, video call, or telehealth. While these are convenient and accessible ways to interact with our team, MODO Mobile Doctor cannot guarantee the confidentiality, privacy, and security of any information transmitted by means of these methods. As such, Member expressly waives our medical staff’s obligation to guarantee confidentiality with respect to correspondence using the aforementioned means of communication. Members also acknowledge that all such interactions may be included in the members medical records. By the member’s signature on the contract page, Member authorizes the MODO Mobile Doctor and team to communicate with Member by these methods of communication regarding Member’s “protected health information” (PHI) as that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996. These methods of communication are not appropriate means of communicating emergencies or other time sensitive issues. Any and all urgent or time-sensitive issues should be relayed to the physician via the designated office phone and VIP line only. Neither MODO Mobile Doctor or any of its employees will be liable for any loss, cost, injury or expense caused by, or resulting from, a delay in responding to Member as a result of tactical failures, including, but not limited to (i) technical issues attributed to any Internet cellular device provider, (ii) power outages, failure of any electronic messaging software, or failure to properly address email messages, (iii) failure of our medical team’s computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of email communication by a third-party; or (v) your future to comply with the guidelines regarding the use of email communication set forth is in the section.

5. Exclusions of Service: The membership fee is for all of the services and privileges detailed within the membership description. This fee does not include other medical care received by the Member. Any additional medical, clinical, diagnostic, and therapeutic services provided to the Member must be paid for separately.

6. Scheduling: Dr. Danesh or his designee, will make every attempt to accommodate an appointment the same or next day, with consideration of the Members medical needs and Member preferred availability. House and work visits will also be accommodated to the best of our ability the same or next day as deemed medically necessary.

7. Concierge Services: Any unused yearly services may not be transferred to the next year. Only IV Vitamin drips (if applicable) may be or gifted to another patient, member, or family member within the package, and must obtain written approval from a MODO staff member. Other services included may not be gifted to anyone else. Any upgrades or additional services can be applied by paying the difference of the price of the services. If a house call is not needed, MODO reserves the right to make the clinically appropriate decision to treat through telemedicine. Patient understands that this package does not serve as a replacement for emergency services. If you cannot make your appointment, you must notify the Concierge Scheduling team 24 hours in advance. Failure to do so will forfeit the specified yearly treatment.

8. Insurance: At this time, MODO Mobile Doctor is non-participating with Medicare, or private insurance, and all services provided by MODO are subject to self-pay.

9. Severability: If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to the legally valid or unenforceable in any jurisdiction to watch it applies, the validity of the remainder of the Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that any provision is consistent with applicable law, and it’s modified form, and that provision shall then be enforceable.

10. Availability: In the event of mandatory business meetings, personal emergencies, or other unforeseen events, The Member’s primary physician, Dr. Reza’s Danesh, contracted through MODO Mobile Doctor may not always be available. In these instances, there will be a designated healthcare provider available to accommodate the medical needs of that Member for the duration of Dr. Reza Danesh’s absence 24 hours a day, 7 days a week.

11. Agreement: This Agreement contains the entire agreement between the parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement.

Notice of Privacy Practices


Uses and Disclosures

Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.

Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.

Health care operations. Your health information may be used as necessary to support the day-to-day activities and management of Dr. Reza Danesh, MD INC dba MODO Mobile Doctor For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

Law enforcement. Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government-mandated reporting.

Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the public health department of the state.

Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purposes other than those listed above requires your specific written authorization.

If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.

Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing purposes when financial remuneration is involved. We may not sell your protected health information without your authorization. We may not use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes.

Additional Uses of Information

Appointment reminders. Your health information will be used by our staff to send you appointment reminders.

Information about treatments. Your health information may be used to send you information on the treatment and management of your medical condition that you may find interesting. We may also send you information describing other health-related products and services that we believe may interest you.

Marketing. Unless you request us not to, there are some marketing activities for which we may use your name and address, to provide you with information about services available at our practice. If you would rather not receive marketing communication from our practice, contact our office by email: modo@modomd.com.

Individual Rights

You have certain rights under the federal privacy standards. These include:

The right to request restrictions on the use and disclosure of your protected health information
The right to receive confidential communications concerning your medical condition and treatment
The right to inspect and copy your protected health information
The right to amend or submit corrections to your protected health information
The right to receive an accounting of how and to whom your protected health information has been disclosed The right to receive a printed copy of this notice

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in
our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.

Dr. Reza Danesh, MD INC dba MODO Mobile Doctor Duties

We are required by law to maintain the privacy of your protected health information and to
provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices outlined in this notice. In the event of a breach of unsecured protected health information, if your information has been compromised it is our duty to notify you.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in
our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.


If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:

Office Manager
Dr. Reza Danesh, MD INC dba MODO Mobile Doctor PO Box 791846
Paia, Hawaii 96779

If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.

Contact Person

The name and address of the person you may contact for further information concerning our privacy practices is:

Office Manager
Dr. Reza Danesh, MD INC dba MODO Mobile Doctor PO Box 791846
Paia, Hawaii 96779
888 663-6631


This notice is effective on or after 07/01/2021.

Financial Policy

Thank you for choosing MODO to provide you with medical care and services.

We are committed to providing you with quality health care.
Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please understand that payment for services is a part of that relationship.
Please ask if you have any questions about our fees, our policies, or your responsibilities.

It is your responsibility to notify our office of any patient information changes (i.e., name, address, telephone, insurance information, etc.)

Fees. The patient is fully and personally responsible for the cost of the medical services rendered by MODO to the Patient and shall pay the same to MODO at the time of service.

Insurance. We do not participate with any insurance companies at this time and are considered out-of-network. We are happy to provide you with a superbill or CMS 1500 form for you to submit to your insurance for reimbursement, this does not guarantee your insurance will reimburse you.

Credit Card: MODO uses HITECH-compliant encrypted software for processing and storage of credit card information.

Refund Policy: Refunds and return payments by Reza Danesh, MD dba MODO Medical Doctor may take up to net 30 days from receipt of the request and are processed via our return/refund payment process. In order to qualify for a refund or return, a letter with your request, the reason for the refund, a copy of the charge, and a bank statement listing the charge must be mailed via certified mail to our office.

Return Payment Policy

Refunds and return payments by Reza Danesh, MD dba MODO Medical Doctor may take up to net 30 days and are processed via our return/refund payment process. In order to qualify for a refund or return, a letter with your request, the reason for the refund, a copy of the charge, and a bank statement listing the charge must be mailed to the address below via certified mail.

MODO Medical Doctor Attn: Accounts Payable PO Box 791846
Paia, Hawaii 967791846

The decision will be sent back to the return address on the original letter and the payment will be returned to the original payment method unless otherwise noted. MODO MD does not issue cash refunds but can make checks payable to the billing party.

General Consent for Care and Treatment

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides us with your permission to perform reasonable and necessary medical examinations, testing, and treatment. By signing below, you are indicating that

1. you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and 2. you consent to treatment at this office or any other satellite office under common ownership.

The consent will remain fully effective until it is revoked in writing.

You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your physician about the purpose, potential risks, and benefits of any test ordered for you.

If you have any concerns regarding any test or treatment recommended by your healthcare provider, we encourage you to ask questions.

I voluntarily request a MODO, physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform a reasonable and necessary medical examination, testing, and treatment for the condition which has brought me to seek care at this practice.

I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

I certify that I have read and fully understand the above statements and consent fully and voluntarily to their contents.

Patient Acknowledgement and Consent:

I have received/reviewed a copy of the notice of privacy practices for Dr. Reza Danesh, MD INC dba MODO Mobile Doctor

I understand that I am responsible to pay for all services rendered by Reza Danesh, MD dba MODO Medical Doctor. I understand that they will not bill my insurance company, but at my request will provide me with forms that I can submit to my insurance company for reimbursement. I understand that reimbursement from my insurance company is not guaranteed.

I have read and agreed to the terms of Return Payment Policy.

I have read the Consent for Treatment and agree to medical treatment and services provided by all MODO representatives and providers. I understand that at any time I can ask questions regarding my diagnosis, treatment, test, or voice concerns and these will be addressed.