Common use of Assignment of Benefits Clause in Contracts

Assignment of Benefits. I hereby assign to SUNCOAST PREMIER MEDICAL LLC any and all benefits from my insurance plans or any other protection maintained by the patient. I authorize and direct such benefits to be paid directly to SUNCOAST PREMIER MEDICAL LLC for services provided. If my insurance plan does not uphold the agreement to pay a claim on my behalf within 30 days of filing, I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint to the Insurance Commissioner in order to be reimburse for professional services. Financial Agreement I, __ ___ __ understand all patients are financially responsible for all services rendered by SUNCOAST PREMIER MEDICAL LLC. Patients with NO Insurance are to pay in full at the time of service. Insurance must be verified and approved prior to acceptance, although this is NOT a guarantee of payment form your insurance company. Office visits, Co-pays, deductibles, and other services not covered by your insurance are to be paid in full at the time of your service. You the Patient remain responsible for payment for services if your insurance company has not paid your claim within 45 calendar days. This facility does use legal means provided by law to collect bad debt accounts and returned checks. Returned checks may be directly withdrawn from your account with a fee applied. Consent for Medical Services I, __ ___ ___ ___ consent to treatment, diagnostic and/or therapeutic services as ordered and/or provided by SUNCOAST PREMIER MEDICAL LLC. I hereby give my permission and consent for SUNCOAST PREMIER MEDICAL LLC and staff to treat me using generally accepted standards of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made nor implied to me. I understand that treatment for my condition(s) will be based upon the information that I provide. I accept full responsibility should I provide inaccurate, incomplete, or misleading information. I certify that the identifying information and address, and telephone informat ion is correct and agree to provide SUNCOAST PREMIER MEDICAL LLC and its staff if such information changes or becomes outdated. I understand that SUNCOAST PREMIER MEDICAL cannot contact me if I have provided incorrect or illegible information or should I not keep this information current and correct. The undersigned certifies that He/She has read and understands s the above and fully accepts all specified terms therein. The undersigned also certifies that He/She has read and understands the Patient Responsibilities Notification provided by SUNCOAST PREMIER MEDICAL LLC. ___________________________________________ ______________ Signature of patient or authorized legal representative Date ____________________________________________ ______________ Signature Date

Assignment of Benefits. In consideration of Island Home Care Agency Inc. awaiting payment, I and/or responsible party hereby assign to SUNCOAST PREMIER MEDICAL LLC any benefits of any/all Insurance Policies covering myself and all benefits from my insurance plans or any other protection maintained by illness for the patientservices rendered. I authorize and/or the responsible party agrees to cooperate fully with all requirements of the Insurance carrier to facilitate payment under this assignment of benefits. Island Home Care Agency Inc., will do everything possible to maximize the return of your insurance coverage by full cooperation and direct such benefits documentation necessary to be paid directly to SUNCOAST PREMIER MEDICAL LLC for services providedimplement those payments. If In the event your carrier denies coverage, we will xxxx you at our customary & reasonable charges. I and/or responsible party understand that my insurance plan does Insurance carrier may not uphold the agreement to pay a claim cover specific item(s) my Physician has ordered on my behalf , and if Island Home Care Agency Inc. has provided such a service, then I and/or responsible party will be billed the difference. In the event payments for Insurance benefits are made directly to any of the undersigned, the payee will endorse all checks for such payments and forward them to Island Home Care Agency Inc., within 30 days 48 hours of filingreceipt. Release of Information The undersigned authorizes the Insurance carrier(s) and any other third party payor(s) to disclose to Island Home Care Agency Inc. any information regarding such benefits, including but not limited to A) Payments made by such Insurance carrier(s), and B) The availability of continuing benefits from time to time. I and/or responsible party authorize Island Home Care Agency Inc. to act as my representative to xxxx and collect money from my Insurance carrier and to initiate a complaint with the State of New York Insurance Department when necessary. I and/or responsible party further authorize Island Home Care Agency Inc. to release all information related to the claim for purposes of facilitating payment of that claim. I and /or the responsible party understand that it would be prudent and in my best interests to establish a Home Health Service Plan of Care in the event of an emergency such as fire, hurricane, severe snowstorm, or other natural disaster. Therefore, I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint and /or the responsible party, hereby grant Island Home Care Agency Inc. permission to reveal to any governmental agency, supplemental provider agency, community volunteer service or other providers of services medical records regarding care, except where otherwise prohibited by law. I and /or the Insurance Commissioner responsible party further understand this would be done as necessary, upon request, in order to be reimburse insure a safe and effective emergency preparedness plan of care. Security Agreement Patient Name: (Address) of hereby grants to Island Home Care Agency Inc., a security interest (right to the proceeds) on Policy # , to secure payment of all obligations for professional services. Financial Agreement Imedical, __ ___ __ understand all patients are financially responsible for all nursing, services rendered by SUNCOAST PREMIER MEDICAL LLCIsland Home Care Agency Inc. during my infirmity. Patients with NO Insurance are Patient authorizes Island Home Care Agency Inc to pay in full at the time of service. Insurance must be verified and approved prior to acceptance, although this is NOT file a guarantee of payment form your insurance company. Office visits, Co-pays, deductibles, and other services not covered by your insurance are to be paid in full at the time of your service. You the Patient remain responsible for payment for services if your insurance company has not paid your claim within 45 calendar days. This facility does use legal means provided by law to collect bad debt accounts and returned checks. Returned checks may be directly withdrawn from your account with a fee applied. Consent for Medical Services I, __ ___ ___ ___ consent to treatment, diagnostic and/or therapeutic services as ordered and/or provided by SUNCOAST PREMIER MEDICAL LLC. I hereby give my permission and consent for SUNCOAST PREMIER MEDICAL LLC and staff to treat me using generally accepted standards of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made nor implied to me. I understand that treatment for my condition(s) will be based upon the information that I provide. I accept full responsibility should I provide inaccurate, incomplete, or misleading information. I certify that the identifying information and address, and telephone informat ion is correct and agree to provide SUNCOAST PREMIER MEDICAL LLC and its staff if such information changes or becomes outdated. I understand that SUNCOAST PREMIER MEDICAL cannot contact me if I have provided incorrect or illegible information or should I not keep this information current and correctfinancing statement. The undersigned certifies that Hehe/She she has read the foregoing and understands s the above and fully accepts all specified terms thereinreceived a copy. The undersigned also certifies that Hehe/She she is the patient, or is duly authorized by the patient as the patient's "significant others" to execute the above items and accept those items and terms. (Patient Signature)/ (Parent/Legal Guardian) Witness Date x (Responsible Party) Date x_Island Home Care Agency Inc. (Signature/ Title) Date Assessment\Pt. Agreement Consent to Treat Island Home Care Agency Inc. 0- 000-000-0000 PATIENT AGREEMENT Patient Name: S.S.#: Patient Address: Phone Number: Date: Request for Provision of Services You have been referred to us by to provide Licensed Health Care Services. We are a Licensed Home Health Care Services Agency. I have received a copy of the “Patient Xxxx of Rights & Responsibilties”,”Service Fees”, “Planning in Advance for your Medical Treatment”, “Appointing your Health Care Proxy and Proxy form”, “Policy on Advanced Directives”, “Notice of Privacy Practices” and “Emergency Preparedness Checklist”. Agreement to Pay and Payment Responsibilities I and/or the responsible party, fully understand that I am liable (or if a responsible party has read signed below, we are liable jointly and understands severally) being responsible for payment of all bills submitted by Island Home Care Agency Inc., for all services rendered. Based upon the Patient Responsibilities Notification information you have provided this Agency and assuming you maintain the insurance in effect throughout the term of care, it is expected that we will receive compensation from your Insurance. However, if you fail to maintain your insurance or your insurance carrier determines you are no longer eligible, the patient and/or responsible party will be responsible for payment in full. The Agency shall advise the patient/responsible party of any changes that they become aware of both orally and in writing as soon as possible, but no later than 30 calendar days from the date the Agency becomes aware of the change. I and/or the responsible party understand that by SUNCOAST PREMIER MEDICAL LLC. ___________________________________________ ______________ Signature signing this agreement, I engage together with Island Home Care Agency Inc. (a provider of patient or authorized legal representative Date ____________________________________________ ______________ Signature Datenursing and health care services).

Assignment of Benefits. I hereby assign authorize direct remittance of payment of all insurance benefits, including Medicaid and Medicare, to SUNCOAST PREMIER MEDICAL LLC any First Baptist Mission Action, Inc. (FBMA) for all covered services provided to me during all courses of treatment and all benefits from my insurance plans or any other protection maintained care provided. I understand and agree this Assignment of Benefits will have continuing effect for so long as I am being treated by the patient. I authorize Ministry of Counseling & Enrichment (MOCE), and direct such benefits to be paid directly to SUNCOAST PREMIER MEDICAL LLC for services provided. If my insurance plan does not uphold the agreement to pay will constitute a claim on my behalf within 30 days continuing authorization of filing, I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint to the Insurance Commissioner any policy that is in order to be reimburse for professional services. Financial Agreement I, __ ___ __ understand all patients are financially responsible for all services rendered by SUNCOAST PREMIER MEDICAL LLC. Patients with NO Insurance are to pay in full effect at the time of service. Insurance must be verified , maintained on file with MOCE, which will authorize and approved prior allow for direct payment to acceptanceFBMA of all applicable and eligible insurance benefits for all subsequent and continuing treatment, although this is NOT a guarantee of payment form your insurance company. Office visits, Co-pays, deductiblesservices, and other services care provided. This serves as a lifetime consent for Medicare. I authorize MOCE to release information from the medical records of the above mentioned client for the purpose of accessing insurance benefits. This information may include diagnoses, date, and type of treatment received. Additional information may be requested before claim payment is made and may include but not covered by your limited to, intake report, treatment plan, progress notes, medications prescribed, and discharge report. Signature of Client: Date: DOB: Signature of Parent/Guardian: Court Fee Agreement Sheet *** THIS FORM MUST BE COMPLETED FULLY BY ALL CLIENTS EVEN IF YOU DO NOT FORSEE COURT AS A POSSIBILITY IN YOUR SITUATION.*** By signing this sheet the client acknowledges that they understand the following expectations and itemized fees: INITIAL EACH The fees for court preparation and appearance are set regardless of insurance co-pay or adjusted fee. Ministry of Counseling & Enrichment clinicians (therapist & psychologist) are to Mental Health Professionals (MHP) and cannot testify in court without being subpoenaed per center policy. The expectation is the initial fee will be paid in full at least 24 hours before mandated court appearance. If the time at court is longer than the initial expected time then compensation for that time will be expected in a timely manner. The client whose attorney subpoenas the MHP will be expected to pay the fees unless the court orders otherwise. Court appearances will require blocking off either a half day or full day depending on the attorney’s expectations and need. The MHP can adjust that amount if it takes less time and they are still able to see other clients in those previously blocked off time slots. Itemized Fees Hourly Rate ● Master’s level MHP- $95.00 per hour ● Doctoral level MHP- $150.00 per hour Prep and Record Review Time ● Up to 3 hours At above hourly rate Court Appearances ● ½ Day At above hourly rate ● Full Day At above hourly rate Travel Cost if Court is out of your serviceAbilene ● Mileage Reimbursement At Current Federal Reimbursement Rate Client Signature Date Credit/Debit Card Authorization Form — Mental Health Services Ministry of Counseling & Enrichment. You * 0000 X 0xx Xxxxxx * Xxxxxxx, XX 00000 Please complete the Patient remain responsible for payment for services if your insurance company has not paid your claim within 45 calendar days. This facility does use legal means provided by law to collect bad debt accounts and returned checks. Returned checks may be directly withdrawn from your account with a fee applied. Consent for Medical Services following information: I, __ ___ ___ ___ consent (print name as it appears on the credit card) authorize First Baptist Mission Action, Inc. to treatment, diagnostic and/or therapeutic services as ordered and/or provided charge my credit card for charges incurred by SUNCOAST PREMIER MEDICAL LLC. I hereby give my permission and consent for SUNCOAST PREMIER MEDICAL LLC and staff to treat me using generally accepted standards (print name of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made nor implied to meclient receiving services). I understand that treatment for per clinic policy, my condition(s) credit card will be based upon charged in the information that event of a failure to keep a scheduled appointment with less than 24 business hours notification as agreed to in the Informed Consent. Furthermore, for any outstanding payments of services rendered, I provideauthorize First Baptist Mission Action, Inc. to charge my card for the full amount due. I accept full responsibility should I provide inaccurate, incomplete, will not dispute charges for sessions that have been received or misleading informationthat have not been cancelled within 24 business hours in advance. I certify that the identifying further authorize First Baptist Mission Action, Inc. to disclose information and address, and telephone informat ion is correct and agree about my attendance or cancellation to provide SUNCOAST PREMIER MEDICAL LLC and its staff my credit card company if such information changes or becomes outdatedI dispute a charge. I understand that SUNCOAST PREMIER MEDICAL cannot contact me if there will be a $25 fee for any declined credit card charge. By signing, I acknowledge that this form serves as prior notice of charges and that I have provided incorrect or illegible read, understood, and agreed to the terms above: Signature: Date: Card Type: (circle one) Visa MasterCard Discover American Express Full Name on Card: Card #: 3 digit Verification Code: Expiration Date: Billing Address for Card: (Street, City, State, and Zip Code) Signature of Card Holder: *This form is considered protected health information or should I not keep this information current and correctwill be securely stored in your clinical file. The undersigned certifies information may be updated upon request at any time. Please note, your credit card will be charged at time of service, whether on line or in person. It will also be charged if there is a no show or if cancellation is less than 24 hours, per agreed upon policy in the informed consent. If you are experiencing financial hardship it is your responsibility to inform the Counseling staff that He/She has read you are unable to make your payment. Ministry of Counseling and understands s Enrichment GOOD FAITH ESTIMATE Provider: TX LPC# 0000 X. 0xx Xxxxxxx XX, 00000 Provider Phone #: (000) 000-0000 Provider Tax ID# 00-0000000 Provider NPI # Patient Name: Patient Date of Birth: Patient Address Patient Diagnosis Services Requested: Date of Initial Session (if applicable): You are entitled to receive this “Good Faith Estimate” of what the above charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and fully accepts all specified terms thereinthe type and amount of services that are provided to you. There may be additional items or services I may recommend as part of your care that must be scheduled or requested separately and are not reflected in this good faith estimate. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here. You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). For questions or more information about your right to a Good Faith Estimate or the dispute process, visit xxxxx://xxx.xxx.xxx/nosurprises/consumers or call 0- 000-000-0000. The undersigned also certifies initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you. The fee for a 50-minute psychotherapy visit (in person or via telehealth) is $ . Most clients will attend one psychotherapy visit per week or once every other week, but the frequency of psychotherapy visits that He/She has read are appropriate in your case may be more or less than once per week, depending upon your needs. Number of Weeks Total estimated charges Master Level therapist for 1 session per week $95 Total estimated charges for Doctoral Clinician 1session per week $150 1 Week of Service $95 $150 13 Weeks of Service (Approx. 3 Months) $1,235 $1950 26 Weeks of Service (Approx. 6 months) $2,470 $3,900 39 Weeks of Service (Approx. 9 months) $3,705 $5,850 52 Weeks of Service (Approx. 12 Months) $4,940 $7,800 This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and understands the Patient Responsibilities Notification estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time. You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided by SUNCOAST PREMIER MEDICAL LLCto you in this Good Faith Estimate. ___________________________________________ ______________ Signature Date of patient or authorized legal representative Date ____________________________________________ ______________ Signature Datethis Estimate

Assignment of Benefits. I hereby assign authorize direct remittance of payment of all insurance benefits, including Medicaid and Medicare, to SUNCOAST PREMIER MEDICAL LLC any First Baptist Mission Action, Inc. (FBMA) for all covered services provided to me during all courses of treatment and all benefits from my insurance plans or any other protection maintained care provided. I understand and agree this Assignment of Benefits will have continuing effect for so long as I am being treated by the patient. I authorize Ministry of Counseling & Enrichment (MOCE), and direct such benefits to be paid directly to SUNCOAST PREMIER MEDICAL LLC for services provided. If my insurance plan does not uphold the agreement to pay will constitute a claim on my behalf within 30 days continuing authorization of filing, I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint to the Insurance Commissioner any policy that is in order to be reimburse for professional services. Financial Agreement I, __ ___ __ understand all patients are financially responsible for all services rendered by SUNCOAST PREMIER MEDICAL LLC. Patients with NO Insurance are to pay in full effect at the time of service. Insurance must be verified , maintained on file with MOCE, which will authorize and approved prior allow for direct payment to acceptanceFBMA of all applicable and eligible insurance benefits for all subsequent and continuing treatment, although this is NOT a guarantee of payment form your insurance company. Office visits, Co-pays, deductiblesservices, and other services care provided. This serves as a lifetime consent for Medicare. I authorize MOCE to release information from the medical records of the above mentioned client for the purpose of accessing insurance benefits. This information may include diagnoses, date, and type of treatment received. Additional information may be requested before claim payment is made and may include but not covered by your limited to, intake report, treatment plan, progress notes, medications prescribed, and discharge report. Signature of Client: Date: DOB: Signature of Parent/Guardian: Court Fee Agreement Sheet *** THIS FORM MUST BE COMPLETED FULLY BY ALL CLIENTS EVEN IF YOU DO NOT FORSEE COURT AS A POSSIBILITY IN YOUR SITUATION.*** By signing this sheet the client acknowledges that they understand the following expectations and itemized fees: INITIAL EACH The fees for court preparation and appearance are set regardless of insurance co-pay or adjusted fee. Ministry of Counseling & Enrichment clinicians (therapist & psychologist) are to Mental Health Professionals (MHP) and cannot testify in court without being subpoenaed per center policy. The expectation is the initial fee will be paid in full at least 24 hours before mandated court appearance. If the time of your service. You at court is longer than the Patient remain responsible initial expected time then compensation for payment for services if your insurance company has not paid your claim within 45 calendar days. This facility does use legal means provided by law to collect bad debt accounts and returned checks. Returned checks may be directly withdrawn from your account with a fee applied. Consent for Medical Services I, __ ___ ___ ___ consent to treatment, diagnostic and/or therapeutic services as ordered and/or provided by SUNCOAST PREMIER MEDICAL LLC. I hereby give my permission and consent for SUNCOAST PREMIER MEDICAL LLC and staff to treat me using generally accepted standards of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made nor implied to me. I understand that treatment for my condition(s) time will be based upon the information that I provide. I accept full responsibility should I provide inaccurate, incomplete, or misleading information. I certify that the identifying information and address, and telephone informat ion is correct and agree to provide SUNCOAST PREMIER MEDICAL LLC and its staff if such information changes or becomes outdated. I understand that SUNCOAST PREMIER MEDICAL cannot contact me if I have provided incorrect or illegible information or should I not keep this information current and correctexpected in a timely manner. The undersigned certifies that He/She has read client whose attorney subpoenas the MHP will be expected to pay the fees unless the court orders otherwise. Court appearances will require blocking off either a half day or full day depending on the attorney’s expectations and understands s the above and fully accepts all specified terms thereinneed. The undersigned also certifies MHP can adjust that He/She has read amount if it takes less time and understands the Patient Responsibilities Notification provided by SUNCOAST PREMIER MEDICAL LLCthey are still able to see other clients in those previously blocked off time slots. ___________________________________________ ______________ Signature Itemized Fees Hourly Rate • Master’s level MHP- $90.00 per hour • Doctoral level MHP- $150.00 per hour Prep and Record Review Time • Up to 3 hours At above hourly rate Court Appearances • ½ Day At above hourly rate • Full Day At above hourly rate Travel Cost if Court is out of patient or authorized legal representative Date ____________________________________________ ______________ Signature DateAbilene • Mileage Reimbursement At Current Federal Reimbursement Rate

Assignment of Benefits. I hereby assign to SUNCOAST PREMIER MEDICAL LLC any and all benefits from my insurance plans or any other protection maintained by the patient. I authorize and direct such benefits request all third parties responsible for any portion of my SHC bill to be paid make payment directly to SUNCOAST PREMIER MEDICAL LLC for services provided. If my insurance plan does not uphold the agreement to pay a claim on my behalf within 30 days of filing, I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint to the Insurance Commissioner in order to be reimburse for professional services. Financial Agreement I, __ ___ __ understand all patients are financially responsible for all services rendered by SUNCOAST PREMIER MEDICAL LLC. Patients with NO Insurance are to pay in full at the time of service. Insurance must be verified and approved prior to acceptance, although this is NOT a guarantee of payment form your insurance company. Office visits, Co-pays, deductibles, and other services not covered by your insurance are to be paid in full at the time of your service. You the Patient remain responsible for payment for services if your insurance company has not paid your claim within 45 calendar days. This facility does use legal means provided by law to collect bad debt accounts and returned checks. Returned checks may be directly withdrawn from your account with a fee applied. Consent for Medical Services I, __ ___ ___ ___ consent to treatment, diagnostic and/or therapeutic services as ordered and/or provided by SUNCOAST PREMIER MEDICAL LLC. I hereby give my permission and consent for SUNCOAST PREMIER MEDICAL LLC and staff to treat me using generally accepted standards of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made nor implied to meSHC. I understand that treatment I am financially responsible to SHC for charges not paid by insurance or other third party payer, unless otherwise prohibited by state or federal regulations. Authorization for Release of Information: I authorize SHC, my condition(streating physicians and their respective designees to use and disclose my health information for treatment, payment and health care purposes, including but not limited to, release of information to any financial sponsor or insurance company of mine as may be required for payment to be made on my account for services rendered. SHC IS ONLY AN IN-NETWORK PROVIDER FOR NYU Sponsored Health Insurance plans (Wellfleet) will United Healthcare commercial products (Excludes Psychiatry) Oxford Freedom and Liberty Plans (Excludes Psychiatry) SHC IS OUT-OF-NETWORK FOR ALL OTHER INSURANCE PLANS AND YOU MAY NOT BE COVERED • SHC uses only Quest and LabCorp for laboratory services. You may receive a separate bill for certain specimen or cultures collected during your medical visit. If your insurance participates with a different lab, please let your provider know and an order can be based upon the information that I provide. I accept full responsibility should I provide inaccurate, incomplete, or misleading information. I certify that the identifying information and address, and telephone informat ion is correct and agree given for you to provide SUNCOAST PREMIER MEDICAL LLC and its staff if such information changes or becomes outdatedtake with you. I understand that SUNCOAST PREMIER MEDICAL canI am responsible for knowing what my insurance plan will and will not contact me if cover. I have provided incorrect or illegible information or should I not keep this information current and correct. The undersigned certifies that He/She has read and understands s understand this form. All of my questions have been answered. N Student ID Number First Name Last Name Signature Date • If you anticipate problems paying your portion of the above and fully accepts all specified terms thereinSHC bill, please contact Patient Accounts (000) 000-0000. The undersigned also certifies that He/She has read and understands the Patient Responsibilities Notification provided by SUNCOAST PREMIER MEDICAL LLC. ___________________________________________ ______________ Signature of patient * Please see Student Health Insurance Guide or authorized legal representative Date ____________________________________________ ______________ Signature Datevisit xxx.xxx.xxx/xxxxxx for details.

Assignment of Benefits. I hereby assign In the event the undersigned is entitled to SUNCOAST PREMIER MEDICAL LLC benefits of any and all benefits from my kind whatsoever arising out of any policy of insurance plans insuring the patient or any other protection maintained party liable to the patient, said benefits are hereby assigned to TMI Sports Medicine & Orthopedics for application on the patients account. The undersigned, and / or patient agree to be responsible for the charges not covered by the patientassignment, including deductibles, coinsurance and co-payments as contracted by each party. I authorize and direct such benefits Financial Agreement: The undersigned agrees that in the consideration for services to be paid directly to SUNCOAST PREMIER MEDICAL LLC for services provided. If my insurance plan does not uphold the agreement to pay a claim on my behalf within 30 days of filing, I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint rendered to the Insurance Commissioner in order patient, he/ she individually agrees to be reimburse for professional services. Financial Agreement I, __ ___ __ understand all patients are financially totally responsible for all charges for services rendered such as DURABLE MEDICAL SUPPLIES and ORTHOVISC and any other non-covered charges. The undersigned agrees to assign payment for the unpaid charges from services provided by SUNCOAST PREMIER MEDICAL LLCphysicians and personnel employed by TMI Sports Medicine & Orthopedics. Patients with NO Insurance I, the undersigned, accept the fee(s) charged as a legal and lawful debt. I understand the fee(s) charged are to pay in full due at the time of service. Insurance must Should it become necessary to forward my account to collections, I agree to pay all monies due, including the collection fee, attorney fee and court fee, if such become necessary. I waive now and forever, my right of exemption under the laws of the Constitution of the State of Texas and any other state. All delinquent balances shall bear interest at the legal rate. Medicare (CMS) Authorization: I authorize any holder of medical or other information about me to release to the Social Security Administration and Center for Medicare Services (CMS) or its intermediaries or carriers any information needed for this or a related Medicare claim. I permit a copy of this authorization to be verified used in place of the original and approved prior request payment of medical insurance benefit, either to acceptancemyself or the party who accepts assignment. I understand it is mandatory to notify the health care provider of any other party who may be responsible in paying for my treatment. Regulations pertaining to Medicare assignment of benefits also apply. Notice of Ownership We care about your health and strive to provide you with the best possible care. Our physician are owners in various medical facilities across the metroplex including Xxxxxx Xxxxx & White Las Colinas Surgical Hospital, although this is NOT a guarantee of payment form your insurance company. Office visits, Co-pays, deductiblesTrinity Park Surgery Center, and other services not covered by Dallas Joint and Spine. Our physician become owners in a facility to provide absolute quality patient care. Ownership in a facility helps facilitate control over quality of care. If you have any questions, please consult your insurance physician. THE UNDERSIGNED CERTIFIES THAT HE/SHE HAD READ AND UNDERSTANDS THE ABOVE INFORMATION AND IS THE PATIENT OR IS DULY AUTHORIZED BY THE PATIENT TO EXECUTE AND ACCEPT THE TERMS THIS CONSENT. NOTICE OF PRIVACY PRACTICES HIPAA Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Effective Date: 07/01/2022. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION, PLEASE CONTACT OUR PRIVACY OFFICER: Privacy Officer Xxxxxxx Xxxx, COO 0000 Xxxxxxx Xxxx, Arlington, TX 76015 000-000-0000 About This Notice We are to be paid in full at the time of your service. You the Patient remain responsible for payment for services if your insurance company has not paid your claim within 45 calendar days. This facility does use legal means provided required by law to collect bad debt accounts maintain the privacy of Protected Health Information and returned checks. Returned checks may be directly withdrawn from your account to give you this Notice explaining our privacy practices with a fee applied. Consent for Medical Services I, __ ___ ___ ___ consent regard to treatment, diagnostic and/or therapeutic services as ordered and/or provided by SUNCOAST PREMIER MEDICAL LLC. I hereby give my permission and consent for SUNCOAST PREMIER MEDICAL LLC and staff to treat me using generally accepted standards of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made nor implied to me. I understand that treatment for my condition(s) will be based upon the information that I provide. I accept full responsibility should I provide inaccurate, incomplete, or misleading information. I certify that You have certain rights – and we have certain legal obligations – regarding the identifying information and addressprivacy of your Protected Health Information, and telephone informat ion this Notice also explains your rights and our obligations. We are required to abide by the terms of the current version of this Notice. What is correct and agree to provide SUNCOAST PREMIER MEDICAL LLC and its staff if such information changes or becomes outdated. I understand that SUNCOAST PREMIER MEDICAL cannot contact me if I have provided incorrect or illegible information or should I not keep this information current and correct. The undersigned certifies that He/She has read and understands s the above and fully accepts all specified terms therein. The undersigned also certifies that He/She has read and understands the Patient Responsibilities Notification provided by SUNCOAST PREMIER MEDICAL LLC. ___________________________________________ ______________ Signature of patient or authorized legal representative Date ____________________________________________ ______________ Signature DateProtected Health Information?

Assignment of Benefits. I hereby assign to SUNCOAST PREMIER MEDICAL LLC the Agency any rights to payment or reimbursement by any insurer, payor, plan, or government health program, otherwise payable to subscriber, to the extent of my account. This form has been explained to me and I have read and understood its content. I understand that my signature on this document will be treated as a contract. If the terms of this contract are not met then the contract will be considered to be in default and my account may be referred to a collection agency, whereupon I agree to pay all benefits from costs incurred. I agree to contact Agency if my insurance plans financial situation changes and to review my fee and payment schedule for possible adjustment. I understand that my agreement may be reassessed periodically. I also understand that Agency rates are subject to change with 30 days notice. I acknowledge receipt of a copy of this form. Client Date Responsible Party Date Clinician Date Relationship to Client Date Signature of parent or any other protection maintained legal guardian is required for minor clients. Form 12.16.21 1 of 1 Client Name / ID: ADVANCE BENEFICIARY NOTICE Client Name: ID#: Your medical benefit may not pay for all of your health care costs. In order for services to be covered, the treatment must be determined by the patientpayor to be “medically necessary” according to the payors respective standards and policies. The fact that certain services may not be covered under your medical benefit does not mean you should not receive the treatment. There may be a good reason your service provider recommended it. Examples of non-covered services that your Medical Benefit may not pay: • Exhausted benefits, • Services provided beyond benefit limits, • Authorization not received due to medical necessity criteria, • Services provided by an out of network/non-preferred provider, • Court ordered treatments, • Case management services, • Non disclosure or insufficient disclosure of full and complete billing information. Other: If it is determined at a later date that the listed service is covered by your benefit then you will be refunded any payments made that are due to you. I authorize and direct such benefits acknowledge that I am responsible for knowing the limits of my medical coverage. I have chosen to receive the described treatment furnished by VCCC even though it may not be paid directly covered by my medical benefit. I take full responsibility for payment of all fees in relation to SUNCOAST PREMIER MEDICAL LLC the above treatment. I understand that I may be eligible for services provided. If my insurance plan does not uphold the agreement to pay a claim sliding fee scale, based on my behalf within 30 days income. Client Signature Date Agency Representative Signature Date Note: The purpose of filing, I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint this form is to help you make an informed choice about whether or not you want to receive the Insurance Commissioner in order to be reimburse for professional recommended services. Financial Agreement IPlease ask for an explanation if you do not understand why your suggested treatment is not covered. FIN0016—9/21/11 FEE SCHEDULE Client Name: ID#: Effective: January 1st, __ ___ __ understand all patients are financially 2013 Scale Discount Adjusted Monthly Income Flat Rate Hourly Rate % From To Intake Doctors/ARNP Services Individual Services Family Services Group Services Case Management A 0% 3,902 and up 165.00 197.50 125.00 130.00 50.00 95.00 B 10% 3,572 3,901 148.50 177.75 112.50 117.00 45.00 85.50 C 20% 3,242 3,571 132.00 158.00 100.00 104.00 40.00 76.00 D 30% 2,912 3,241 115.50 138.25 87.50 91.00 35.00 66.50 E 40% 2,582 2,911 99.00 118.50 75.00 78.00 30.00 57.00 F 50% 2,252 2,581 82.50 98.75 62.50 65.00 25.00 47.50 G 60% 1,922 2,251 66.00 79.00 50.00 52.00 20.00 38.00 H 70% 1,592 1,921 49.50 59.25 37.50 39.00 15.00 28.50 I 80% 1,262 1,591 33.00 39.50 25.00 26.00 10.00 19.00 J 90% 932 1,261 16.50 19.75 12.50 13.00 5.00 9.50 K 100% 0** 931 - - - - - - ******************************************************* Adjusted Monthly Income is calculated as the household gross Income less $330.00 per any additional person in the household ******************************************************* Consumer is responsible for all services rendered by SUNCOAST PREMIER MEDICAL LLC. Patients with NO Insurance are to pay in full co-insurance or co-payments at the time of serviceservice ******************************************************* Third Party Insurance is always billed at VCCC established full fee ******************************************************* ** In keeping with Washington State administrative code, we offer a special $0.00 fee for consumers eligible for services who have incomes below the grant standards for the general assistance program. Insurance must be verified and approved prior to acceptance, although this is NOT a guarantee ******************************************************* Adjusted Monthly Income & Sliding Scale calculation: Gross Monthly Income: (a) # of payment form your insurance company. Office visits, Co-pays, deductibles, and other services not covered by your insurance are Dependents: (b) Amount to be paid in full at the time of your service. You the Patient remain responsible for payment for services if your insurance company has not paid your claim within 45 calendar days. This facility does use legal means provided by law Adjusted: (c) (b)*$330.00 Adjusted Monthly Income: (d) (a)-(c) Scale: (refer to collect bad debt accounts and returned checks. Returned checks may be directly withdrawn from your account with a fee applied. Consent for Medical Services Iscale above) Discount: (refer to scale above) % Client Signature: Date: FIN0002—9/21/11 Rev 1/10/13 RECEIPT OF DOCUMENTS By signing below, __ ___ ___ ___ consent to treatment, diagnostic and/or therapeutic services as ordered and/or provided by SUNCOAST PREMIER MEDICAL LLC. I hereby give my permission and consent for SUNCOAST PREMIER MEDICAL LLC and staff to treat me using generally accepted standards of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made nor implied to me. I understand that treatment for my condition(s) will be based upon the information that I provide. I accept full responsibility should I provide inaccurate, incomplete, or misleading information. I certify that I have received: • Valley Cities Consumer Handbook • A clinical staff Disclosure Statement • Valley Cities Notice of Privacy Practices • King County Notice of Privacy Practices • Washington State Publication What to Expect from your Licensed Counselor. • Washington State Publication Mental Health Advance Directives, Information for Consumers (for clients 18+ and emancipated minors) By signing below, I also acknowledge that I have read and understand my client rights. Client Signature: Date: CONFIDENTIALITY Generally, the identifying information you pass on to a clinician is not discussed outside of your treatment team. Valley Cities will not disclose information that you have given unless: • You sign a release of information authorizing us to disclose this information (parents of children twelve (12) and addressunder are responsible for providing this permission). • Your clinician thinks you are in danger of harming yourself or someone else. • Your clinician has any reason to suspect a child, a developmentally disabled person, or an elderly person is being abused or neglected. • The release of information is court ordered or otherwise legally required. • Other reasons for release as allowed or required by law, specified in the Notice of Privacy Practices and telephone informat ion is correct and agree the Washington Department of Health brochure What to provide SUNCOAST PREMIER MEDICAL LLC and its staff if such information changes Expect from your Licensed Counselor. • Family members or becomes outdated. I understand that SUNCOAST PREMIER MEDICAL friends cannot contact me if see or receive information about your records without a signed release. Your clinician cannot tell them anything without your written permission, but can listen to information they share or give them general information about mental illness and services that are available. By signing this form, I acknowledge that I have provided incorrect or illegible information or should I not keep this information current and correct. The undersigned certifies that He/She has read and understands s the above and fully accepts all specified terms thereinacknowledge this information. The undersigned also certifies that He/She has read and understands the Patient Responsibilities Notification provided by SUNCOAST PREMIER MEDICAL LLC. ___________________________________________ ______________ Signature of patient or authorized legal representative Date ____________________________________________ ______________ Signature Client Signature: Date:

Assignment of Benefits. IN CONSIDERATION of the willingness of to treat me on credit without demand for payment at the time services are rendered, I hereby agree and stipulate as follows: I irrevocably assign to SUNCOAST PREMIER MEDICAL LLC any proceeds or compensation that I am or may become entitled to receive as a result of injuries that occurred on to the extent of the chiropractic services rendered. I make this agreement without prejudice to any rights I may have to prosecute legal claims against any party who may be liable for my injuries, but I hereby authorize and all benefits instruct you to pay directly to , from any disability benefits, medical payments benefits, liability benefits, health and accident benefits, workers compensation benefits, judgments, settlements, or proceeds of any kind that would otherwise be payable to me, such sums as are due to for its services rendered. I appoint as my insurance plans attorney in fact to affix my name as an endorsement upon the reverse of any check or draft upon which I am a named payee and to deposit said check or draft and apply the proceeds to any other protection maintained by the patientunpaid balance I may have with . I authorize to release to any insurer with applicable coverage or to my attorney or successor attorney any information regarding my injuries, prior medical history, or treatment as may be necessary to facilitate collection of proceeds under this assignment. I acknowledge that I remain personally liable for the total amount due to for services rendered, including any balance remaining after the application of insurance payments and direct such settlement or judgment proceeds. If is required to take legal action against me to recover any unpaid balance on my account, I agree to reimburse for its costs of recovery, including reasonable attorney’s fees. I further agree this assignment of benefits (AOB) cannot be revoked and the right to receive payment cannot be transferred to any other party or re-asserted by me in anyway. Patient: Date: Witness: NOTICE OF LIEN Pursuant to N.C.G.S. 44‐49 and 44‐50, hereby asserts and gives notice of a lien upon any sums recovered in damages for personal injury in any civil action and also upon all funds paid to the above‐named patient in compensation for or settlement of injuries sustained, whether in litigation or otherwise. xxxxxx requests that if it’s claim is not paid completely from the foregoing proceeds, a full disclosure and account of proceeds be provided in conformity with N.C.G.S. 44‐50.1. agrees to be paid directly to SUNCOAST PREMIER MEDICAL LLC for services providedbound by any confidentiality agreements regarding the content of the accounting. If my insurance plan does not uphold the agreement to pay a claim on my behalf within 30 days of filing, I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint to the Insurance Commissioner in order to be reimburse for professional services. Financial Agreement I, __ ___ __ understand all patients are financially responsible for all services rendered by SUNCOAST PREMIER MEDICAL LLC. Patients with NO Insurance are to pay in full at the time of service. Insurance must be verified and approved prior to acceptance, although this is NOT a guarantee of payment form your insurance company. Office visits, Co-pays, deductibles, and other services not covered by your insurance are to be paid in full at the time of your service. You the Patient remain responsible for payment for services if your insurance company has not paid your claim within 45 calendar days. This facility does use legal means provided by law to collect bad debt accounts and returned checks. Returned checks may be directly withdrawn from your account with a fee applied. Consent for Medical Services I, __ ___ ___ ___ consent to treatment, diagnostic and/or therapeutic services as ordered and/or provided by SUNCOAST PREMIER MEDICAL LLC. I hereby give my permission and consent for SUNCOAST PREMIER MEDICAL LLC and staff to treat me using generally accepted standards of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made nor implied to me. I understand that treatment for my condition(s) will be based upon the information that I provide. I accept full responsibility should I provide inaccurate, incomplete, or misleading information. I certify that the identifying information and address, and telephone informat ion is correct and agree to provide SUNCOAST PREMIER MEDICAL LLC and its staff if such information changes or becomes outdated. I understand that SUNCOAST PREMIER MEDICAL cannot contact me if I have provided incorrect or illegible information or should I not keep this information current and correct. The undersigned certifies that He/She has read and understands s the above and fully accepts all specified terms therein. The undersigned also certifies that He/She has read and understands the Patient Responsibilities Notification provided by SUNCOAST PREMIER MEDICAL LLC. ___________________________________________ ______________ Signature of patient or authorized legal representative Date ____________________________________________ ______________ Signature Date

Assignment of Benefits. I hereby assign request that payment of authorized Medicare, Medicaid, or private insurance benefits be made payable to SUNCOAST PREMIER MEDICAL LLC METHOD HCS or any covered services furnished to me by METHOD HCS. I authorize any holder of medical information about me to be released to the Center for Medicare and Medicaid Services and its agents, TRICARE and its agents, or to any private insurance company or information needed to determine these benefits or the benefits payable to related services. Payment Agreement: I understand that by my signature I requested that payment be made, and I authorize release of information necessary to pay the claim for covered services. In Medicare and Medicaid assigned cases, METHOD HCS agrees to accept the charge determination of the insurance carrier as the full charge for covered services; I agree to transfer immediately to METHOD HCS any payment made directly to me for services by METHOD HCS on an assigned basis. In addition, if payment is made to me, and if I do not transfer payments to Method HCS, I agree to be responsible for the full amount of the charges and all collections and legal remedies including fees. Operational Instruction Policy: I understand I will receive instruction in the proper use and care of any and all benefits items delivered by METHOD HCS and METHOD HCS is available by phone to answer any questions I may have from time to time after receiving my insurance plans or any other protection maintained by the patient. items and I authorize and direct such benefits will be required to be paid directly to SUNCOAST PREMIER MEDICAL LLC for services provided. If my insurance plan does not uphold the agreement to pay a claim on my behalf within 30 days make written acknowledgement of filing, I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint to the Insurance Commissioner in order to be reimburse for professional services. Financial Agreement I, __ ___ __ understand all patients are financially responsible for all services rendered by SUNCOAST PREMIER MEDICAL LLC. Patients with NO Insurance are to pay in full receiving operational instructions at the time of servicedelivery. HIPAA Consent: I understand that under the Health Insurance must Portability & Accountability Act of 1996 (HIPAA), I have certain rights regarding my protected health information. I understand that my health information can and will be verified used to (1) directly and approved prior to acceptanceindirectly conduct, although this is NOT a guarantee of plan or prescribe my treatment, and follow-up among multiple healthcare providers; (2) obtain payment form your insurance company. Office visitsfrom Medicare, Co-pays, deductiblesmy supplemental insurance, and other services not covered third party payers; and (3) conduct normal healthcare operations such as quality assessments and physician certifications. Return Policy: I understand any item delivered by your insurance are METHOD HCS may be returned for a full refund within 7 days if the item is in re-salable condition and in the original packaging and I will be required to be paid in full make written acknowledgement of receiving return policy information at the time of your servicedelivery. You the Patient remain responsible for payment for services if your insurance company has not paid your claim within 45 calendar days. This facility does use legal means provided by law to collect bad debt accounts and returned checks. Returned checks may be directly withdrawn from your account with a fee applied. Consent for Medical Services I, __ ___ ___ ___ consent to treatment, diagnostic and/or therapeutic services as ordered and/or provided by SUNCOAST PREMIER MEDICAL LLC. I hereby give my permission and consent for SUNCOAST PREMIER MEDICAL LLC and staff to treat me using generally accepted standards of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made nor implied to me. Complaint Procedure Policy: I understand that treatment for my condition(s) will be based upon the information that I provide. I accept full responsibility should I provide inaccurate, incomplete, or misleading information. I certify that the identifying information and address, and telephone informat ion is correct and agree to provide SUNCOAST PREMIER MEDICAL LLC and its staff if such information changes or becomes outdated. I understand that SUNCOAST PREMIER MEDICAL cannot contact me if I have provided incorrect a complaint about any item delivered by METHOD HCS or illegible any representative of METHOD HCS, I may call the owner or store manager of METHOD HCS at 000-000-0000, and I will be required to make written acknowledgement of receiving complaint procedure information or should I not keep this information current and correct. The undersigned certifies that He/She has read and understands s at the above and fully accepts all specified terms therein. The undersigned also certifies that He/She has read and understands the Patient Responsibilities Notification provided by SUNCOAST PREMIER MEDICAL LLC. ___________________________________________ ______________ Signature time of patient or authorized legal representative Date ____________________________________________ ______________ Signature Datedelivery.

Assignment of Benefits. I hereby assign authorize direct remittance of payment of all insurance benefits, including Medicaid and Medicare, to SUNCOAST PREMIER MEDICAL LLC any First Baptist Mission Action, Inc. (FBMA) for all covered services provided to me during all courses of treatment and all benefits from my insurance plans or any other protection maintained care provided. I understand and agree this Assignment of Benefits will have continuing effect for so long as I am being treated by the patient. I authorize Ministry of Counseling & Enrichment (MOCE), and direct such benefits to be paid directly to SUNCOAST PREMIER MEDICAL LLC for services provided. If my insurance plan does not uphold the agreement to pay will constitute a claim on my behalf within 30 days continuing authorization of filing, I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint to the Insurance Commissioner any policy that is in order to be reimburse for professional services. Financial Agreement I, __ ___ __ understand all patients are financially responsible for all services rendered by SUNCOAST PREMIER MEDICAL LLC. Patients with NO Insurance are to pay in full effect at the time of service. Insurance must be verified , maintained on file with MOCE, which will authorize and approved prior allow for direct payment to acceptanceFBMA of all applicable and eligible insurance benefits for all subsequent and continuing treatment, although this is NOT a guarantee of payment form your insurance company. Office visits, Co-pays, deductiblesservices, and other services not covered by your insurance are to be paid in full at the time of your service. You the Patient remain responsible for payment for services if your insurance company has not paid your claim within 45 calendar dayscare provided. This facility does use legal means provided by law serves as a lifetime consent for Medicare. I authorize MOCE to collect bad debt accounts release information from the medical records of the above mentioned client for the purpose of accessing insurance benefits. This information may include diagnoses, date, and returned checkstype of treatment received. Returned checks Additional information may be directly withdrawn from your account with a fee applied. Consent for Medical Services Irequested before claim payment is made and may include but not limited to, __ ___ ___ ___ consent to treatmentintake report, diagnostic and/or therapeutic services as ordered and/or provided by SUNCOAST PREMIER MEDICAL LLC. I hereby give my permission and consent for SUNCOAST PREMIER MEDICAL LLC and staff to treat me using generally accepted standards of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made nor implied to me. I understand that treatment for my condition(s) will be based upon the information that I provide. I accept full responsibility should I provide inaccurateplan, incompleteprogress notes, or misleading information. I certify that the identifying information and addressmedications prescribed, and telephone informat ion is correct and agree to provide SUNCOAST PREMIER MEDICAL LLC and its staff if such information changes or becomes outdateddischarge report. I understand that SUNCOAST PREMIER MEDICAL cannot contact me if I have provided incorrect or illegible information or should I not keep this information current and correct. The undersigned certifies that He/She has read and understands s the above and fully accepts all specified terms therein. The undersigned also certifies that He/She has read and understands the Patient Responsibilities Notification provided by SUNCOAST PREMIER MEDICAL LLC. ___________________________________________ ______________ Signature of patient or authorized legal representative Date Client: Date: DOB: Client Name: ____________________________________________ Signature of Parent/Guardian: Court Fee Agreement *** THIS FORM MUST BE COMPLETED FULLY BY ALL CLIENTS EVEN IF YOU DO NOT FORSEE COURT AS A POSSIBILITY IN YOUR SITUATION.*** By signing this sheet the client acknowledges that they understand the following expectations and itemized fees: INITIAL EACH The fees for court preparation and appearance are set regardless of insurance co-pay or adjusted fee. Ministry of Counseling & Enrichment clinicians (therapist & psychologist) are Mental Health Professionals (MHP) and cannot testify in court without being subpoenaed per center policy. The expectation is the initial fee will be paid in full at least 24 hours before mandated court appearance. If the time at court is longer than the initial expected time then compensation for that time will be expected in a timely manner. The client whose attorney subpoenas the MHP will be expected to pay the fees unless the court orders otherwise. Court appearances will require blocking off either a half day or full day depending on the attorney’s expectations and need. The MHP can adjust that amount if it takes less time and they are still able to see other clients in those previously blocked off time slots. Hourly Rate Itemized Fees  Master’s level MHP- $95.00 per hour  Doctoral level MHP- $150.00 per hour Prep and Record Review Time  Minimum of 3 hours At above hourly rate Court Appearances  ½ Day At above hourly rate  Full Day At above hourly rate Travel Cost if Court is out of Abilene  Mileage Reimbursement At Current Federal Reimbursement Rate Client Name: ______________ Signature Date_______________________________

Assignment of Benefits. I hereby assign authorize all insurance payments to SUNCOAST PREMIER MEDICAL LLC any and all benefits from be made to the designated provider of Compassion Centered Counseling. This assignment will remain in effect until revoked by me in writing. I understand that this order does not relieve me of my obligation to pay such bills if not paid by my insurance plans company, or any other protection maintained balance due after payments by the patient. I authorize and direct such benefits to be paid directly to SUNCOAST PREMIER MEDICAL LLC for services provided. If my insurance plan does not uphold company. It is the agreement client’s responsibility to pay a claim on my behalf within 30 days of filing, I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint to provide our office with the Insurance Commissioner correct insurance information in order to file claims with the insurance company. Claims not paid due to incorrect information will then become the client’s responsibility. If you are more than 15 minutes late for your appointment, you will be reimburse responsible for professional servicesthe $65.00 fee for the session, which is not reimbursable by insurance. Financial Agreement I, __ ___ __ I understand all patients are that I am financially responsible to Compassion Centered Counseling for all services rendered the charges incurred by SUNCOAST PREMIER MEDICAL LLCmyself and/or my dependents. Patients (If you are not filing insurance you do not have to sign this segment). Signature of Client/Responsible Party Print Name Date Additional Client Signature (Spouse, /Partner, Family Member) Print Name Date PROFESSIONAL RECORDS: The laws and standards of the profession require that CCC keep treatment records. You are entitled to receive a copy of your records, or your therapist can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we recommend that you review them in the presence of your counselor so that she/he can discuss the contents. Clients will be charged an appropriate fee for any professional time spent in responding to information requests. GRIEVANCES: I also acknowledge that I may submit a Grievance to the Provider at any time to register a complaint about any aspect of my care. If I am not satisfied with NO Insurance the responses I receive, I may submit the Grievance to the address below: v To report a rules violation by this licensee, contact the appropriate Board: Texas State Board of Examiners of Licensed Professional Counselors v At the following address: P.O. Box 141369, Austin, TX 78714-1369 OR (0-000-000-0000) Signature of Client/Responsible Party Print Name Date Additional Client Signature (Spouse, /Partner, Family Member) Print Name Date ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES: I understand I have a right to review Compassion Centered Counseling (henceforth referred to as CCC) Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my Protected Health Information (henceforth referred to as PHI) that will occur in my treatment, payment of bills and the rights I have regarding my PHI. I consent to the use of disclosure of my PHI for these purposes. I understand I have the right to request a restriction as to how my PHI is used or disclosed to carry out treatment, payment or healthcare operations of the practice. CCC is not required to agree to the restrictions that I may request. However, if CCC agrees to a restriction that I request, the restriction is binding on CCC and my counselor. I also understand that if these restrictions limit the ability of my insurance to pay, I will be held responsible for the entire fee up front. I have the right to revoke this consent, in writing, at any time, except to the extent that my counselor or CCC has already taken action based on this consent. The Notice of Privacy for CCC is provided upon request. CCC reserves the right to change the privacy practices that are to pay described in full the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or by requesting one at the time of servicean appointment. Insurance must be verified and approved prior to acceptance, although this is NOT a guarantee of payment form your insurance company. Office visits, Co-pays, deductibles, and other services not covered by your insurance are to be paid in full at the time of your service. You the Patient remain responsible for payment for services if your insurance company has not paid your claim within 45 calendar days. This facility does use legal means provided by law to collect bad debt accounts and returned checks. Returned checks may be directly withdrawn from your account with a fee applied. Consent for Medical Services I, __ ___ ___ ___ consent to treatment, diagnostic and/or therapeutic services as ordered and/or provided by SUNCOAST PREMIER MEDICAL LLC. I hereby give my permission and consent for SUNCOAST PREMIER MEDICAL LLC and staff to treat me using generally accepted standards of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made nor implied to me. I understand that treatment for my condition(s) will be based upon the information that I provide. I accept full responsibility should I provide inaccurate, incomplete, or misleading information. I certify that the identifying information and address, and telephone informat ion is correct and agree to provide SUNCOAST PREMIER MEDICAL LLC and its staff if such information changes or becomes outdated. I understand that SUNCOAST PREMIER MEDICAL cannot contact me if I have provided incorrect or illegible information or should I not keep this information current and correct. The undersigned certifies that He/She has read and understands s the above and fully accepts all specified terms therein. The undersigned also certifies that He/She has read and understands the Patient Responsibilities Notification provided by SUNCOAST PREMIER MEDICAL LLC. ___________________________________________ ______________ Signature of patient or authorized legal representative Date ____________________________________________ ______________ Signature Client/Responsible Party Print Name Date

Assignment of Benefits. I hereby assign to SUNCOAST PREMIER MEDICAL LLC Xxxxx Xxxxxxx the right to submit a pre-service appeal to my health plan on my behalf. Mediation Agreement (applicable to Maryland only): I understand that any claim that may arise out of the care provided from the doctors, nurses and all benefits from my insurance plans or other health care providers at any other protection maintained Xxxxx Xxxxxxx entity located in the state of Maryland are governed by the patientlaws of the State of Maryland. I authorize agree that before I file any lawsuit, I will try to resolve my claim through mediation. Mediation is a process through which a neutral third person assists the parties to help settle the claim. I do not give up my right to file a lawsuit if the mediation process fails to resolve my claim. I agree that any mediation or action in court must take place in Maryland. This agreement is binding on me and direct such benefits to be paid directly to SUNCOAST PREMIER MEDICAL LLC for services provided. If my insurance plan does not uphold the agreement to pay anyone who makes a claim on my behalf within 30 days for me. The Xxxxx Xxxxxxx Notice of filingPrivacy Practices: I received a copy of the Xxxxx Xxxxxxx Notice of Privacy Practices. Consent for the Creation and Use of Photographs, Audio and Video Recordings (PAVR): ): I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint acknowledge that I have received the Xxxxx Xxxxxxx Photographs, Audio and Video Recording Patient Information Guide. I agree to allow for the Insurance Commissioner in order to be reimburse for professional services. Financial Agreement Icreation and use of photographs, __ ___ __ understand all patients are financially responsible for all services rendered by SUNCOAST PREMIER MEDICAL LLC. Patients with NO Insurance are to pay in full at the time of service. Insurance must be verified audio and approved prior to acceptancevideo, although this is NOT a guarantee of payment form your insurance company. Office visits, Co-pays, deductiblesrecordings (PAVR), and other services images and recordings of me, or the patient I represent, for the purposes of internal education and quality improvement. Initial one: I authorize I do not covered by your insurance are to be paid in full at authorize Other Tests: In the time event that a member of your service. You the Patient remain responsible for payment for services if your insurance company has not paid your claim within 45 calendar days. This facility does use legal means provided by law to collect bad debt accounts and returned checks. Returned checks may be directly withdrawn from your account with hospital’s work force sustains a fee applied. Consent for Medical Services Ibodily fluid exposure during the course of my treatment, __ ___ ___ ___ I consent to treatment, diagnostic and/or therapeutic services as ordered and/or provided by SUNCOAST PREMIER MEDICAL LLC. I hereby give my permission HIV testing and consent for SUNCOAST PREMIER MEDICAL LLC and staff authorize the hospital to treat me using generally accepted standards release the result of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made nor implied this said test to me, the exposed healthcare employee, and my physician. I understand that treatment I have the right to refuse testing without penalty. I authorize I do not authorize Interpreter: If interpreter used, please complete the following: Remote In-person Interpreter ID Number (if phone/video interpreter used): Date: Time: Printed Name of Interpreter: I AGREE TO THE ITEMS STATED ABOVE AND CERTIFY THAT ALL INFORMATION PROVIDED INCLUDING INSURANCE IS ACCURATE AND CORRECT TO THE BEST OF MY KNOWLEDGE. NO CHANGES TO THIS FORM WILL BE ACCEPTED. Date: Time: Patient Signature: For health care agent / guardian / surrogate / parent / spouse (circle one), I, (print name), am the representative for the patient. Date: Time: Representative’s signature: Relationship to Patient: Date: Time: XXXXX XXXXXXX NOTICES Pathology: Xxxxx Xxxxxxx may dispose of any tissue or parts that are removed during a procedure; may retain, preserve, use, and share these tissues, parts or related information for internal educational and quality improvement purposes without my condition(s) will be based upon the permission (even when these tissues, parts or related information identify me); and may use or share tissues, parts or related information that identifies me for research with my permission or with the approval of a review board governed by federal laws protecting these activities. If tissues, parts or related information do not identify me, Xxxxx Xxxxxxx may use them for scientific (research) purposes without my permission or action by a review board. Pathology (Florida): I provide. I accept full responsibility should I provide inaccurateauthorize Xxxxx Xxxxxxx to dispose of any tissue or parts that are removed during a procedure; to retain, incompletepreserve, or misleading information. I certify that the identifying information and addressuse, and telephone informat ion is correct share these tissues, parts or related information, including any related DNA analysis, for internal education, research, quality improvement and agree other healthcare operations purposes, and as otherwise permitted by federal and state privacy laws, even when these tissues, parts or related information identify me. Personal Belongings: Patients are responsible for their personal belongings and are encouraged to leave all money and valuables at home. Xxxxx Xxxxxxx shall not be responsible or liable for the loss of or damage to any personal property the patient brought into the facility including but not limited to money, dentures, glasses, hearing aids, personal electronic devices and documents. Financial Assistance: II understand that Xxxxx Xxxxxxx has Financial Assistance Policies which provide SUNCOAST PREMIER MEDICAL LLC financial assistance and its staff if such information changes or becomes outdatedpayment plans to patients under certain circumstances. I understand that SUNCOAST PREMIER MEDICAL cannot I can request information concerning Xxxxx Xxxxxxx Financial Assistance by contacting the Customer Service Department for Xxxxx Xxxxxxx at 000-000-0000 or 0-000-000-0000. I hereby authorize Xxxxx Xxxxxxx to run a credit report on me for use in determining whether I qualify for financial assistance or a payment plan. I also understand that I can obtain information by going online at: xxx.xxxxxxxxxxxxxxx.xxx/xxxxxxx_xxxx/xxx_xxxx/xxxxxxx_xxxxxxxxxx.xxxx Physicians have their own financial assistance policies and the patient should contact me if I have provided incorrect or illegible information or should I not keep this information current and correct. The undersigned certifies that He/She has read and understands s the above and fully accepts all specified terms therein. The undersigned also certifies that He/She has read and understands the Patient Responsibilities Notification provided by SUNCOAST PREMIER MEDICAL LLC. ___________________________________________ ______________ Signature of patient or authorized legal representative Date ____________________________________________ ______________ Signature Datephysician’s office to inquire.

Assignment of Benefits. In consideration of Island Home Care Agency Inc. awaiting payment, I and/or responsible party hereby assign to SUNCOAST PREMIER MEDICAL LLC any benefits of any/all Insurance Policies covering myself and all benefits from my insurance plans or any other protection maintained by illness for the patientservices rendered. I authorize and/or the responsible party agrees to cooperate fully with all requirements of the Insurance carrier to facilitate payment under this assignment of benefits. Island Home Care Agency Inc., will do everything possible to maximize the return of your insurance coverage by full cooperation and direct such benefits documentation necessary to be paid directly to SUNCOAST PREMIER MEDICAL LLC for services providedimplement those payments. If In the event your carrier denies coverage, we will xxxx you at our customary & reasonable charges. I and/or responsible party understand that my insurance plan does Insurance carrier may not uphold the agreement to pay a claim cover specific item(s) my Physician has ordered on my behalf , and if Island Home Care Agency Inc. has provided such a service, then I and/or responsible party will be billed the difference. In the event payments for Insurance benefits are made directly to any of the undersigned, the payee will endorse all checks for such payments and forward them to Island Home Care Agency Inc., within 30 days 48 hours of filingreceipt. Release of Information The undersigned authorizes the Insurance carrier(s) and any other third party payor(s) to disclose to Island Home Care Agency Inc. any information regarding such benefits, including but not limited to A) Payments made by such Insurance carrier(s), and B) The availability of continuing benefits from time to time. I and/or responsible party authorize Island Home Care Agency Inc. to act as my representative to xxxx and collect money from my Insurance carrier and to initiate a complaint with the State of New York Insurance Department when necessary. I and/or responsible party further authorize Island Home Care Agency Inc. to release all information related to the claim for purposes of facilitating payment of that claim. I and /or the responsible party understand that it would be prudent and in my best interests to establish a Home Health Service Plan of Care in the event of an emergency such as fire, hurricane, severe snowstorm, or other natural disaster. Therefore, I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint and /or the responsible party, hereby grant Island Home Care Agency Inc. permission to reveal to any governmental agency, supplemental provider agency, community volunteer service or other providers of services medical records regarding care, except where otherwise prohibited by law. I and /or the Insurance Commissioner responsible party further understand this would be done as necessary, upon request, in order to be reimburse insure a safe and effective emergency preparedness plan of care. Security Agreement Patient Name: (Address) of hereby grants to Island Home Care Agency Inc., a security interest (right to the proceeds) on Policy # , to secure payment of all obligations for professional services. Financial Agreement Imedical, __ ___ __ understand all patients are financially responsible for all nursing, services rendered by SUNCOAST PREMIER MEDICAL LLCIsland Home Care Agency Inc. during my infirmity. Patients with NO Insurance are Patient authorizes Island Home Care Agency Inc to pay in full at the time of service. Insurance must be verified and approved prior to acceptance, although this is NOT file a guarantee of payment form your insurance company. Office visits, Co-pays, deductibles, and other services not covered by your insurance are to be paid in full at the time of your service. You the Patient remain responsible for payment for services if your insurance company has not paid your claim within 45 calendar days. This facility does use legal means provided by law to collect bad debt accounts and returned checks. Returned checks may be directly withdrawn from your account with a fee applied. Consent for Medical Services I, __ ___ ___ ___ consent to treatment, diagnostic and/or therapeutic services as ordered and/or provided by SUNCOAST PREMIER MEDICAL LLC. I hereby give my permission and consent for SUNCOAST PREMIER MEDICAL LLC and staff to treat me using generally accepted standards of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made nor implied to me. I understand that treatment for my condition(s) will be based upon the information that I provide. I accept full responsibility should I provide inaccurate, incomplete, or misleading information. I certify that the identifying information and address, and telephone informat ion is correct and agree to provide SUNCOAST PREMIER MEDICAL LLC and its staff if such information changes or becomes outdated. I understand that SUNCOAST PREMIER MEDICAL cannot contact me if I have provided incorrect or illegible information or should I not keep this information current and correctfinancing statement. The undersigned certifies that Hehe/She she has read the foregoing and understands s the above and fully accepts all specified terms thereinreceived a copy. The undersigned also certifies that Hehe/She has read she is the patient, or is duly authorized by the patient as the patient's "significant others" to execute the above items and understands the accept those items and terms. (Patient Responsibilities Notification provided by SUNCOAST PREMIER MEDICAL LLC. ___________________________________________ ______________ Signature of patient or authorized legal representative Signature)/ (Parent/Legal Guardian) Witness Date ____________________________________________ ______________ Signature x (Responsible Party) Date x_Island Home Care Agency Inc. (Signature/ Title) Date

Assignment of Benefits. I hereby assign to SUNCOAST PREMIER MEDICAL LLC any and all benefits from my insurance plans or any other protection maintained by the patient. understand that I authorize and direct such benefits to be paid directly to SUNCOAST PREMIER MEDICAL LLC for services provided. If my insurance plan does not uphold the agreement to pay a claim on my behalf within 30 days of filing, I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint to the Insurance Commissioner in order to be reimburse for professional services. Financial Agreement I, __ ___ __ understand all patients are am financially responsible for all services rendered by SUNCOAST PREMIER MEDICAL LLC. Patients with NO Insurance are to pay in full at the time of service. Insurance must be verified and approved prior to acceptance, although this is NOT a guarantee of payment form your insurance company. Office visits, Co-pays, deductibles, and other services charges whether or not covered by your insurance are to be paid in full at the time of your service. You the Patient remain responsible for payment for services if your insurance company has not paid your claim within 45 calendar days. This facility does use legal means provided by law to collect bad debt accounts and returned checks. Returned checks may be directly withdrawn from your account with a fee applied. Consent for Medical Services I, __ ___ ___ ___ consent to treatment, diagnostic and/or therapeutic services as ordered and/or provided by SUNCOAST PREMIER MEDICAL LLCinsurance. I hereby give my permission and consent authorize the release of any medical or other information necessary to process any claim for SUNCOAST PREMIER MEDICAL LLC and staff to treat me using generally accepted standards of medical care. I am aware hereby authorize the Practice to bill my insurance company and/or Medicare/Medicaid for services provided to me and request that medicine payments for such services to made to the Practice on my behalf. Signature: Date: Primary Insurance Insurance Company Name: Phone: Effective Date:_ Billing Address: Group Number: Policy or ID Number: Secondary Insurance Insurance Company Name: Phone: Effective Date: Billing Address: Group Number: Policy or ID Number: NOTICE OF PRIVACY PRACTICES CONSENT AND ACKNOWLEDGEMENT Our Notice of Privacy Practices provides information about how XXXX X XXXX MD PA, XX. XXXX X MESA, MD may use and surgery are not exact sciences and no guarantee disclose protected health information about you. I consent to the use or disclosure of my protected health information by XXXX X XXXX MD PA, XX. XXXX X MESA, MD for successful outcome has been made nor implied the purpose of diagnosing treatment to me, obtaining payment for my health care bill or to conduct health care operations of XXXX X XXXX MD PA, XX. XXXX X MESA, MD. I acknowledge that I have been provided with the Practice's Notice of Privacy Practices that provides a description of Protected Health In formation uses and disclosures. I understand that treatment for my condition(s) will be based upon I have the information that I provide. I accept full responsibility should I provide inaccurate, incomplete, or misleading information. I certify that right to review the identifying information and address, and telephone informat ion is correct and agree Notice of Privacy Practices prior to provide SUNCOAST PREMIER MEDICAL LLC and its staff if such information changes or becomes outdatedsigning this statement. I understand that SUNCOAST PREMIER MEDICAL canthe Practice reserves the right to change its Notice of Privacy Practices that will be effective for the health information the Practice already has about me, as well as any they receive in the future. I understand that I may obtain a copy of the current Notice in effect upon request. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand that the Practice is not contact me required to agree to my requested restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. List of Names with whom we can share medical information: Name: Relationship: Phone: Name: Relationship: Phone: Do you want any mail sent to you from our office marked as "Confidential''? YES NO Can appointment reminders and other confidential messages be left on your voice mail? YES NO Patient Signature: Date: ************************************************************************************************** OFFICE USE ONLY: I attempted to obtain the patient's signature in acknowledgement of this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below. (Please print) Name: Date: Reason: Authorization for Disclosure of Health Information Last Name: First Name: Middle: Date of Birth: Phone: Mailing Address: Street Apt City State Zip I authorize the use or disclosure of the above-named individual's health information as described below, by: The type and amount of information to be used or disclosed is as follows: (include dates where appropriate). Complete health records Medical exam Immunization record Lab results/X-ray reports Consultation reports Other (please specify) I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency Virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse. This information may be disclosed to and used by the following individual or organization: XXXX X XXXX MD PA, XX. XXXX X MESA, MD. For the purpose of: I understand that I have a right to revoke this authorization at any time. I understand that if I have revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: . If I fail to specify an expiration date, event or condition, this authorization will expire in 365 days. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form to receive continued treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided incorrect in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. Signature of participant or illegible information or should I not keep this information current and correct. The undersigned certifies that He/She has read and understands s the above and fully accepts all specified terms therein. The undersigned also certifies that He/She has read and understands the Patient Responsibilities Notification provided by SUNCOAST PREMIER MEDICAL LLC. ___________________________________________ ______________ Signature representative Date Name of patient or authorized legal representative Date ____________________________________________ ______________ Description of personal representative's authority Print Name of Patient / Guarantor / Legal Guardian: DOB: Signature Dateof Patient / Guarantor / Legal Guardian: CONSENT OF TREATMENT: I authorize the staff at XXXX X XXXXX MD PA to provide any diagnostic test and examination indicated for treatment. Initial:

Assignment of Benefits. I hereby assign to SUNCOAST PREMIER MEDICAL LLC any acknowledge and all benefits from my insurance plans or any other protection maintained by the patient. agree that payment(s) I authorize and direct such benefits to be paid directly to SUNCOAST PREMIER MEDICAL LLC owe for services provided. If my insurance plan does not uphold the agreement to pay a claim on my behalf within 30 days of filing, I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint to the Insurance Commissioner in order to be reimburse for professional services. Financial Agreement I, __ ___ __ understand all patients are financially responsible for all services rendered by SUNCOAST PREMIER MEDICAL you will be assigned and directed to First Colonies Anesthesia Associates LLC. Patients with NO Insurance are In the event that third party payers, insurance companies, or other entities forward such payment(s) to pay in full me, I agree to assign and direct the payment(s) to you immediately upon receipt. Such payment(s) should be delivered to: First Colonies Anesthesia Associates, LLC, P.O. Box 791344, Baltimore, MD 21279-1344 Guarantee of Payment I understand that services rendered by you for my treatment at the time this surgery center will require payment, and I acknowledge and accept complete responsibility for such payment. I further acknowledge, accept responsibility for, and guarantee payment of service. Insurance must be verified and approved prior to acceptancedeductibles, although this is NOT a guarantee of payment form your insurance company. Office visits, Coco-pays, deductibles, and other services or any fees not covered by my insurance company, or any third party payer that were incurred by me as a result of your treatment. If it is determined that no insurance are company or third party payer is obligated to be paid pay for such services, or that proceeds from a liability claim will not yield payment for the professional services rendered to you by me, I guarantee such payment. I will make such payment in full at no later than three months from the time date on which services were rendered to me by you. Should this account be forwarded to a collection agency and/or attorney for collection of your service. You the Patient remain responsible any amounts owed by me, I also acknowledge and accept responsibility for payment for services if your insurance company has not paid your claim within 45 calendar daysof all reasonable collection and/or attorney's fees. This facility does use legal means provided Printed Name of Person Signing this Form Signature of patient/Responsible Party Date: Time: AM/PM Witness: Date: Time: AM/PM NOTICE OF PRIVACY PRACTICE as mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Effective April 14, 2003 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. Monocacy Surgery Center, LLC (MSC) is required by law to collect bad debt accounts maintain the privacy of your health information and returned checksto provide you with notice of its legal duties and privacy practices with respect to your health information. Returned checks may be directly withdrawn from your account with a fee applied. Consent for Medical Services I, __ ___ ___ ___ consent to treatment, diagnostic and/or therapeutic services as ordered and/or provided by SUNCOAST PREMIER MEDICAL LLC. I hereby give my permission and consent for SUNCOAST PREMIER MEDICAL LLC and staff to treat me using generally accepted standards If you have questions about any part of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made nor implied to me. I understand that treatment for my condition(s) will be based upon the information that I provide. I accept full responsibility should I provide inaccurate, incompletethis notice, or misleading information. I certify that if you want more information about the identifying privacy practices at MSC, please see the contact information and address, and telephone informat ion is correct and agree to provide SUNCOAST PREMIER MEDICAL LLC and its staff if such information changes or becomes outdated. I understand that SUNCOAST PREMIER MEDICAL cannot contact me if I have provided incorrect or illegible information or should I not keep at the end of this information current and correct. The undersigned certifies that He/She has read and understands s the above and fully accepts all specified terms therein. The undersigned also certifies that He/She has read and understands the Patient Responsibilities Notification provided by SUNCOAST PREMIER MEDICAL LLC. ___________________________________________ ______________ Signature of patient or authorized legal representative Date ____________________________________________ ______________ Signature Datedocument.

Assignment of Benefits. I hereby assign authorize direct remittance of payment of all insurance benefits, including Medicaid and Medicare, to SUNCOAST PREMIER MEDICAL LLC any First Baptist Mission Action, Inc. (FBMA) for all covered services provided to me during all courses of treatment and all benefits from my insurance plans or any other protection maintained care provided. I understand and agree this Assignment of Benefits will have continuing effect for so long as I am being treated by the patient. I authorize Ministry of Counseling & Enrichment (MOCE), and direct such benefits to be paid directly to SUNCOAST PREMIER MEDICAL LLC for services provided. If my insurance plan does not uphold the agreement to pay will constitute a claim on my behalf within 30 days continuing authorization of filing, I authorize SUNCOAST PREMIER MEDICAL LLC file a complaint to the Insurance Commissioner any policy that is in order to be reimburse for professional services. Financial Agreement I, __ ___ __ understand all patients are financially responsible for all services rendered by SUNCOAST PREMIER MEDICAL LLC. Patients with NO Insurance are to pay in full effect at the time of service. Insurance must be verified , maintained on file with MOCE, which will authorize and approved prior allow for direct payment to acceptanceFBMA of all applicable and eligible insurance benefits for all subsequent and continuing treatment, although this is NOT a guarantee of payment form your insurance company. Office visits, Co-pays, deductiblesservices, and other services care provided. This serves as a lifetime consent for Medicare. I authorize MOCE to release information from the medical records of the above mentioned client for the purpose of accessing insurance benefits. This information may include diagnoses, date, and type of treatment received. Additional information may be requested before claim payment is made and may include but not covered by your limited to, intake report, treatment plan, progress notes, medications prescribed, and discharge report. Signature of Client: Date: DOB: Signature of Parent/Guardian: Court Fee Agreement Sheet *** THIS FORM MUST BE COMPLETED FULLY BY ALL CLIENTS EVEN IF YOU DO NOT FORSEE COURT AS A POSSIBILITY IN YOUR SITUATION.*** By signing this sheet the client acknowledges that they understand the following expectations and itemized fees: INITIAL EACH The fees for court preparation and appearance are set regardless of insurance co-pay or adjusted fee. Ministry of Counseling & Enrichment clinicians (therapist & psychologist) are to Mental Health Professionals (MHP) and cannot testify in court without being subpoenaed per center policy. The expectation is the initial fee will be paid in full at least 24 hours before mandated court appearance. If the time of your service. You at court is longer than the Patient remain responsible initial expected time then compensation for payment for services if your insurance company has not paid your claim within 45 calendar days. This facility does use legal means provided by law to collect bad debt accounts and returned checks. Returned checks may be directly withdrawn from your account with a fee applied. Consent for Medical Services I, __ ___ ___ ___ consent to treatment, diagnostic and/or therapeutic services as ordered and/or provided by SUNCOAST PREMIER MEDICAL LLC. I hereby give my permission and consent for SUNCOAST PREMIER MEDICAL LLC and staff to treat me using generally accepted standards of medical care. I am aware that medicine and surgery are not exact sciences and no guarantee for successful outcome has been made nor implied to me. I understand that treatment for my condition(s) time will be based upon the information that I provide. I accept full responsibility should I provide inaccurate, incomplete, or misleading information. I certify that the identifying information and address, and telephone informat ion is correct and agree to provide SUNCOAST PREMIER MEDICAL LLC and its staff if such information changes or becomes outdated. I understand that SUNCOAST PREMIER MEDICAL cannot contact me if I have provided incorrect or illegible information or should I not keep this information current and correctexpected in a timely manner. The undersigned certifies that He/She has read client whose attorney subpoenas the MHP will be expected to pay the fees unless the court orders otherwise. Court appearances will require blocking off either a half day or full day depending on the attorney’s expectations and understands s the above and fully accepts all specified terms thereinneed. The undersigned also certifies MHP can adjust that He/She has read amount if it takes less time and understands the Patient Responsibilities Notification provided by SUNCOAST PREMIER MEDICAL LLCthey are still able to see other clients in those previously blocked off time slots. ___________________________________________ ______________ Signature Itemized Fees Hourly Rate • Master’s level MHP- $95.00 per hour • Doctoral level MHP- $150.00 per hour Prep and Record Review Time • Up to 3 hours At above hourly rate Court Appearances • ½ Day At above hourly rate • Full Day At above hourly rate Travel Cost if Court is out of patient or authorized legal representative Date ____________________________________________ ______________ Signature DateAbilene • Mileage Reimbursement At Current Federal Reimbursement Rate