Common use of Beneficiary Obligations Clause in Contracts

Beneficiary Obligations. The Beneficiary, or his or her legal representative, accepts full responsibility for payment of the charges for all services furnished by the Physician. The Beneficiary, or his or her legal representative, understands that no payment will be provided by Medicare for items or services furnished by the Physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. The Beneficiary, or his or her legal representative, understands that Medicare limits or any other Medicare reimbursement regulations do not apply to what may be charged for items or services furnished by the Physician. The Beneficiary, or his or her legal representative, agrees not to submit a claim, nor ask the Physician to submit a claim, to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare. The Beneficiary, or his or her legal representative, acknowledges that this written private contract contains sufficiently large print to ensure that the Beneficiary, or his or her legal representative, is able to read this contract. The Beneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for their covered services, and that the Beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. The Beneficiary, or his or her legal representative, understands that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. The Beneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the Physician during a time when the Beneficiary requires emergency care services or urgent care services, except that the Physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440. The Beneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the Beneficiary, or to his or her legal representative, before items or services have been furnished to the Beneficiary under the terms of this contract. The Beneficiary, or his or her legal representative, understands that during the Opt-out period, a Medicare Advantage plan may not by law make any payments to the Physician for any Medicare items and services furnished to the Beneficiary under this contract. Xxxxxxx X. Xxxxx, DO 1467779819 Name of Physician National Provider Identifier Contact: c/o Carah Medical Arts, 000 Xxx Xx, 0xx Xx, Xxxxxxxxxxxx, XX 00000; phone: 000-000-0000. Signature of Physician Date (MM/DD/YYYY) Name of Beneficiary Date of Birth (MM/DD/YYYY) Name of Legal Representative (if different from above) Relationship to Patient Member Signature of Beneficiary or Legal Representative Date (MM/DD/YYYY) 000 Xxx Xxxxxx, 0xx Xxxxx Xxxxxxxxxxxx, XX 00000 This authorization gives permission to release and disclose health information about the named individual to Carah Medical Arts. Patient Name: _ Date of Birth (MM/DD/YYYY): Please enter name and, if available, address of healthcare entity whom you authorize to disclose health information on the line below: is authorized to release and disclose the health information of the above named individual as described in this authorization: Carah Medical Arts, 000 Xxx Xxxxxx, 0xx Xxxxx, Xxxxxxxxxxxx, XX 00000, Phone: 000-000-0000, Fax: 000-000-0000. Substance abuse records (drug or alcohol) Yes ❑ No ❑ Initials Mental health records protected by the Mental Health Procedures Act Yes ❑ No ❑ Initials HIV/AIDS related information Yes ❑ No ❑ Initials I understand that I have the following rights: • Right not to sign. Refusal to sign will not affect my ability to obtain treatment at the clinic operated by Carah Medical Arts.

Beneficiary Obligations. The Beneficiary, or his or her legal representative, accepts full responsibility for payment of the charges for all services furnished by the Physician. The Beneficiary, or his or her legal representative, understands that no payment will be provided by Medicare for items or services furnished by the Physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. The Beneficiary, or his or her legal representative, understands that Medicare limits or any other Medicare reimbursement regulations do not apply to what may be charged for items or services furnished by the Physician. The Beneficiary, or his or her legal representative, agrees not to submit a claim, nor ask the Physician to submit a claim, to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare. The Beneficiary, or his or her legal representative, acknowledges that this written private contract contains sufficiently large print to ensure that the Beneficiary, or his or her legal representative, is able to read this contract. The Beneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for their covered services, and that the Beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. The Beneficiary, or his or her legal representative, understands that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. The Beneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the Physician during a time when the Beneficiary requires emergency care services or urgent care services, except that the Physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440. The Beneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the Beneficiary, or to his or her legal representative, before items or services have been furnished to the Beneficiary under the terms of this contract. The Beneficiary, or his or her legal representative, understands that during the Opt-out period, a Medicare Advantage plan may not by law make any payments to the Physician for any Medicare items and services furnished to the Beneficiary under this contract. Xxxxxxx X. Xxxxx, DO 1467779819 MD 1912294992 Name of Physician National Provider Identifier Contact: c/o Carah Medical Arts, 000 Xxx Xx, 0xx Xx, Xxxxxxxxxxxx, XX 00000; phone: 000-000-0000. Signature of Physician Date (MM/DD/YYYY) Name of Beneficiary Date of Birth (MM/DD/YYYY) Name of Legal Representative (if different from above) Relationship to Patient Member Signature of Beneficiary or Legal Representative Date (MM/DD/YYYY) 000 Xxx XxxxxxThis contract is entered into by and between Xxxxxxx X. Xxxxx, 0xx Xxxxx XxxxxxxxxxxxDO (“Physician”), XX 00000 and the Patient Member (“Beneficiary”). The Physician has informed the Beneficiary that Physician has opted out of the Medicare program effective as of October 1, 2021, for a period of at least two years. This authorization gives permission to release and disclose health information about the named individual to Carah Medical Arts. Patient Name: _ Date of Birth (MM/DD/YYYY): Please enter name and, if available, address of healthcare entity whom you authorize to disclose health information contract shall become effective on the line below: day it is authorized to release entered into by the Beneficiary and disclose shall expire on the health information 1st day of October 2023 (“Opt-out period”), unless otherwise renewed in accordance with the 42 U. S. C. 1395a; 42 C.F.R. 405, Subpart D. The Physician acknowledges that she is not excluded from Medicare under sections 1128, 1156, 1892 or any other section of the above named individual as described Social Security Act. The Physician acknowledges that this contract shall not be entered into with the Beneficiary, or the Beneficiary's legal representative, during a time when the Beneficiary requires emergency care services or urgent care services, except that the Physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440. The Physician acknowledges that she must retain this authorization: Carah Medical Artscontract (with original signatures of both parties to this contract) for the duration of the Opt-out period, 000 Xxx Xxxxxxand that it shall be made available to the Centers for Medicare and Medicaid Services (CMS) upon request. The Physician shall provide a copy of this contract to the Beneficiary, 0xx Xxxxxor to his or her legal representative, Xxxxxxxxxxxx, XX 00000, Phone: 000before items or services have been furnished to the Beneficiary under the terms of this contract. The physician acknowledges that she must enter into a contract for each opt-000-0000, Fax: 000-000-0000. Substance abuse records (drug or alcohol) Yes ❑ No ❑ Initials Mental health records protected by the Mental Health Procedures Act Yes ❑ No ❑ Initials HIV/AIDS related information Yes ❑ No ❑ Initials I understand that I have the following rights: • Right not to sign. Refusal to sign will not affect my ability to obtain treatment at the clinic operated by Carah Medical Artsout period.

Beneficiary Obligations. The Beneficiary, or his or her legal representative, accepts full responsibility for payment of the charges Physician's charge for all services furnished by the Physician. The Beneficiary, or his or her legal representative, understands that no payment will be provided by Medicare for items or services furnished by the Physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. The Beneficiary, or his or her legal representative, understands that Medicare limits or any other Medicare reimbursement regulations do not apply to what the Physician may be charged charge for items or services furnished by the Physician. The Beneficiary, or his or her legal representative, agrees not to submit a claim, nor ask the Physician to submit a claim, to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare. The Beneficiary, or his or her legal representative, Beneficiary acknowledges that this written private contract contains sufficiently large print to ensure that the Beneficiary, or his or her legal representative, Beneficiary is able to read this contract. The Beneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for their covered services, and that the Beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. The Beneficiary, or his or her legal representative, understands that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. The Beneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the Physician during a time when the Beneficiary requires emergency care services or urgent care services, except that the Physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440. The Beneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the Beneficiary, or to his or her legal representative, before items or services have been furnished to the Beneficiary under the terms of this contract. The Beneficiary, or his or her legal representative, understands I understand that during the Optopt-out period, a Medicare Advantage plan may not by law make any payments to the Physician for any Medicare items and services furnished to the Beneficiary under this contract. Xxxxxxx X. Xxxxx, DO 1467779819 Name of Physician National Provider Identifier Contact: c/o Carah Medical Arts, 000 Xxx Xx, 0xx Xx, Xxxxxxxxxxxx, XX 00000; phone: 000-000-0000. Signature of Physician Date (MM/DD/YYYY) Name of Beneficiary Date of Birth (MM/DD/YYYY) Name of Legal Representative (if different from above) Relationship to Patient Member Signature of Beneficiary or Legal Representative Date (MM/DD/YYYY) 000 Xxx Xxxxxx, 0xx Xxxxx Xxxxxxxxxxxx, XX 00000 This authorization gives permission to release and disclose health information about the named individual to Carah Medical Arts. Patient Name: _ Date of Birth (MM/DD/YYYY): Please enter name and, if available, address of healthcare entity whom you authorize to disclose health information on the line below: is authorized to release and disclose the health information of the above named individual as described in this authorization: Carah Medical Arts, 000 Xxx Xxxxxx, 0xx Xxxxx, Xxxxxxxxxxxx, XX 00000, Phone: 000-000-0000, Fax: 000-000-0000. Substance abuse records (drug or alcohol) Yes ❑ No ❑ Initials Mental health records protected by the Mental Health Procedures Act Yes ❑ No ❑ Initials HIV/AIDS related information Yes ❑ No ❑ Initials I understand that I have the following rights: • Right not to sign. Refusal to sign will not affect my ability to obtain treatment at the clinic operated by Carah Medical Arts.

Beneficiary Obligations. 2.1 Beneficiary or his or her legal representative agrees, understands and expressly acknowledges the following: a. The Beneficiary, or his or her legal representative, acknowledges that the Physician has informed the Beneficiary, or his or her legal representative, that the Physician has opted out of the Medicare program effective on for a period of at least two (2) years and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act. b. The Beneficiary, or his or her legal representative, accepts full responsibility for payment of the charges Physician's charge for all services furnished by the Physician. . c. The Beneficiary, or his or her legal representative, understands that no payment will be provided by Medicare for items or services furnished by the Physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. . d. The Beneficiary, or his or her legal representative, understands that Medicare limits or any other Medicare reimbursement regulations do not apply to what the Physician may be charged charge for items or services furnished by the Physician. . e. The Beneficiary, or his or her legal representative, agrees not to submit a claim, nor ask the Physician to submit a claim, to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare. . f. The Beneficiary, or his or her legal representative, Beneficiary acknowledges that he/she has read and sufficiently understood this written private contract contains sufficiently large print to ensure that the Beneficiary, or his or her legal representative, is able to read this contract. . g. The Beneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for their covered services, and that the Beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. . h. The Beneficiary, or his or her legal representative, understands that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. . i. The Beneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the Physician during a time when the Beneficiary requires emergency care services or urgent care services, except that the Physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440. . j. The Beneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the Beneficiary, or to his or her legal representative, before items or services have been furnished to the Beneficiary under the terms of this contract. . k. The Beneficiary, or his or her legal representative, understands acknowledges and agrees that during the Optopt-out period, a Medicare Advantage plan may not by law make any payments to the Physician for any Medicare items and services furnished to the Beneficiary under this contract. Xxxxxxx X. Xxxxx, DO 1467779819 Name of Physician National Provider Identifier Contact: c/o Carah Medical Arts, 000 Xxx Xx, 0xx Xx, Xxxxxxxxxxxx, XX 00000; phone: 000-000-0000. Signature of Physician Date (MM/DD/YYYY) Name of Beneficiary Date of Birth (MM/DD/YYYY) Name of Legal Representative (if different from above) Relationship to Patient Member Signature of Beneficiary or Legal Representative Date (MM/DD/YYYY) 000 Xxx Xxxxxx, 0xx Xxxxx Xxxxxxxxxxxx, XX 00000 This authorization gives permission to release and disclose health information about the named individual to Carah Medical Arts. Patient Name: _ Date of Birth (MM/DD/YYYY): Please enter name and, if available, address of healthcare entity whom you authorize to disclose health information on the line below: is authorized to release and disclose the health information of the above named individual as described in this authorization: Carah Medical Arts, 000 Xxx Xxxxxx, 0xx Xxxxx, Xxxxxxxxxxxx, XX 00000, Phone: 000-000-0000, Fax: 000-000-0000. Substance abuse records (drug or alcohol) Yes ❑ No ❑ Initials Mental health records protected by the Mental Health Procedures Act Yes ❑ No ❑ Initials HIV/AIDS related information Yes ❑ No ❑ Initials I understand that I have the following rights: • Right not to sign. Refusal to sign will not affect my ability to obtain treatment at the clinic operated by Carah Medical Arts.

Beneficiary Obligations. a. The Beneficiary, or his or his/her legal representative, accepts full responsibility for payment of the charges for all services furnished by the hereby agrees to enter into this Contract with Physician. The Beneficiary, or his or his/her legal representative, understands and acknowledges that no payment will be provided Physician is not a contracting HMO provider. b. The Beneficiary, or his/her legal representative, acknowledges that Beneficiary is covered by Medicare for items a Health Maintenance Organization (HMO). c. The Beneficiary, or services furnished his/her legal representative, acknowledges and confirms that: i. Beneficiary was not referred to Physician by the HMO or its agent; and ii. Beneficiary’s HMO has not and/or will not preauthorize or otherwise approve the provision of services by Physician to Beneficiary. d. The Beneficiary, or his/her legal representative, enters this Contract with the knowledge that would have otherwise been he/she has the right to obtain HMO-covered by Medicare if there was no private contract services from HMO-provider physicians and a proper Medicare claim had been submittedpractitioners. The Beneficiary, or his his/her legal representative, acknowledges to have deliberately chosen to obtain the Physician’s services without utilizing his/her HMO coverage. e. The Beneficiary, or his/her legal representative, understands that Medicare limits and acknowledges the financial consequences of his/her decision to access Physician, a non-contracting provider, outside the HMO plan. f. The Beneficiary, or any other Medicare reimbursement regulations do his/her legal representative, promises not apply to what may be charged utilize his/her HMO coverage for items or services furnished by the Physician's services. The Beneficiary, or his or his/her legal representative, agrees agree to not to submit a claim, nor ask the Physician to submit a claim, claim to Medicare the HMO for Medicare items or services, even if such items or services are otherwise covered by Medicare. the HMO. g. The Beneficiary, or his his/her legal representative, understands and acknowledges that the HMO will not pay Physician, and that Physician will not accept payment from the HMO. h. The Beneficiary, or his/her legal representative, agrees to be wholly and solely responsible to pay Physician directly for the entirety of all of Physician’s fees and charges for services provided to Beneficiary. i. The Beneficiary, or his/her legal representative, understands and acknowledges that the Physician’s fees and charges for services furnished by the Physician are not limited by the HMO. j. The Beneficiary, or his/her legal representative, further understands and acknowledges that this Contract arrangement will have no effect on the HMO member's obligation to pay the HMO's premiums. k. The Beneficiary, or his/her legal representative, acknowledges that this written private contract Contract contains sufficiently large print to ensure that the Beneficiary, or his or her legal representative, Beneficiary is able to read this contractContract. The Beneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for their covered services, and that the Beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. The Beneficiary, or his or her legal representative, understands that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. The Beneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the Physician during a time when the Beneficiary requires emergency care services or urgent care services, except that the Physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440. The Beneficiary, or his or his/her legal representative, acknowledges that a copy of this contract Contract has been provided to the Beneficiary, or to his or his/her legal representative, before items or services have been furnished to the Beneficiary under the terms of this contract. The Beneficiary, or his or her legal representative, understands that during the Opt-out period, a Medicare Advantage plan may not by law make any payments to the Physician for any Medicare items and services furnished to the Beneficiary under this contract. Xxxxxxx X. Xxxxx, DO 1467779819 Name of Physician National Provider Identifier Contact: c/o Carah Medical Arts, 000 Xxx Xx, 0xx Xx, Xxxxxxxxxxxx, XX 00000; phone: 000-000-0000. Signature of Physician Date (MM/DD/YYYY) Name of Beneficiary Date of Birth (MM/DD/YYYY) Name of Legal Representative (if different from above) Relationship to Patient Member Signature of Beneficiary or Legal Representative Date (MM/DD/YYYY) 000 Xxx Xxxxxx, 0xx Xxxxx Xxxxxxxxxxxx, XX 00000 This authorization gives permission to release and disclose health information about the named individual to Carah Medical Arts. Patient Name: _ Date of Birth (MM/DD/YYYY): Please enter name and, if available, address of healthcare entity whom you authorize to disclose health information on the line below: is authorized to release and disclose the health information of the above named individual as described in this authorization: Carah Medical Arts, 000 Xxx Xxxxxx, 0xx Xxxxx, Xxxxxxxxxxxx, XX 00000, Phone: 000-000-0000, Fax: 000-000-0000. Substance abuse records (drug or alcohol) Yes ❑ No ❑ Initials Mental health records protected by the Mental Health Procedures Act Yes ❑ No ❑ Initials HIV/AIDS related information Yes ❑ No ❑ Initials I understand that I have the following rights: • Right not to sign. Refusal to sign will not affect my ability to obtain treatment at the clinic operated by Carah Medical Arts.

Beneficiary Obligations. The Beneficiary, or his or her legal representative, accepts full responsibility for payment of the charges for all services furnished by the Physician. The Beneficiary, or his or her legal representative, understands that no payment will be provided by Medicare for items or services furnished by the Physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. The Beneficiary, or his or her legal representative, understands that Medicare limits or any other Medicare reimbursement regulations do not apply to what may be charged for items or services furnished by the Physician. The Beneficiary, or his or her legal representative, agrees not to submit a claim, nor ask the Physician to submit a claim, to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare. The Beneficiary, or his or her legal representative, acknowledges that this written private contract contains sufficiently large print to ensure that the Beneficiary, or his or her legal representative, is able to read this contract. The Beneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for their covered services, and that the Beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. The Beneficiary, or his or her legal representative, understands that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. The Beneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the Physician during a time when the Beneficiary requires emergency care services or urgent care services, except that the Physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440. The Beneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the Beneficiary, or to his or her legal representative, before items or services have been furnished to the Beneficiary under the terms of this contract. The Beneficiary, or his or her legal representative, understands that during the Opt-out period, a Medicare Advantage plan may not by law make any payments to the Physician for any Medicare items and services furnished to the Beneficiary under this contract. Xxxxxxx X. Xxxxx, DO 1467779819 MD 1912294992 Name of Physician National Provider Identifier Contact: c/o Carah Medical Arts, 000 Xxx Xx, 0xx Xx, Xxxxxxxxxxxx, XX 00000; phone: 000-000-0000. Signature of Physician Date (MM/DD/YYYY) Name of Beneficiary Date of Birth (MM/DD/YYYY) Name of Legal Representative (if different from above) Relationship to Patient Member Signature of Beneficiary or Legal Representative Date (MM/DD/YYYY) 000 Xxx XxxxxxThis contract is entered into by and between Xxxxxxx X. Xxxxx, 0xx Xxxxx XxxxxxxxxxxxDO (“Physician”), XX 00000 and the Patient Member (“Beneficiary”). The Physician has informed the Beneficiary that Physician has opted out of the Medicare program effective as of October 1, 2019, for a period of at least two years. This authorization gives permission to release and disclose health information about the named individual to Carah Medical Arts. Patient Name: _ Date of Birth (MM/DD/YYYY): Please enter name and, if available, address of healthcare entity whom you authorize to disclose health information contract shall become effective on the line below: day it is authorized to release entered into by the Beneficiary and disclose shall expire on the health information 1st day of October 2021 (“Opt-out period”), unless otherwise renewed in accordance with the 42 U. S. C. 1395a; 42 C.F.R. 405, Subpart D. The Physician acknowledges that she is not excluded from Medicare under sections 1128, 1156, 1892 or any other section of the above named individual as described Social Security Act. The Physician acknowledges that this contract shall not be entered into with the Beneficiary, or the Beneficiary's legal representative, during a time when the Beneficiary requires emergency care services or urgent care services, except that the Physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440. The Physician acknowledges that she must retain this authorization: Carah Medical Artscontract (with original signatures of both parties to this contract) for the duration of the Opt-out period, 000 Xxx Xxxxxxand that it shall be made available to the Centers for Medicare and Medicaid Services (CMS) upon request. The Physician shall provide a copy of this contract to the Beneficiary, 0xx Xxxxxor to his or her legal representative, Xxxxxxxxxxxx, XX 00000, Phone: 000before items or services have been furnished to the Beneficiary under the terms of this contract. The physician acknowledges that she must enter into a contract for each opt-000-0000, Fax: 000-000-0000. Substance abuse records (drug or alcohol) Yes ❑ No ❑ Initials Mental health records protected by the Mental Health Procedures Act Yes ❑ No ❑ Initials HIV/AIDS related information Yes ❑ No ❑ Initials I understand that I have the following rights: • Right not to sign. Refusal to sign will not affect my ability to obtain treatment at the clinic operated by Carah Medical Artsout period.

Beneficiary Obligations. The Beneficiarybeneficiary, or his or her legal representative, accepts full responsibility for payment of the charges physician's charge for all services furnished by the Physicianphysician. The Beneficiarybeneficiary, or his or her legal representative, understands that no payment will be provided by Medicare for items or services furnished by the Physician physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. The Beneficiarybeneficiary, or his or her legal representative, understands that Medicare limits or any other Medicare reimbursement regulations do not apply to what the physician may be charged charge for items or services furnished by the Physicianphysician. The Beneficiarybeneficiary, or his or her legal representative, agrees not to submit a claim, nor ask the Physician physician to submit a claim, to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare. The Beneficiary, or his or her legal representative, beneficiary acknowledges that this written private contract contains sufficiently large print to ensure that the Beneficiary, or his or her legal representative, beneficiary is able to read this contract. The Beneficiarybeneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for their covered services, and that the Beneficiary beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. The Beneficiarybeneficiary, or his or her legal representative, understands that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. The Beneficiarybeneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the Physician physician during a time when the Beneficiary beneficiary requires emergency care services or urgent care services, except that the Physician physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440. The Beneficiarybeneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the Beneficiarybeneficiary, or to his or her legal representative, before items or services have been furnished to the Beneficiary beneficiary under the terms of this contract. The Beneficiary, or his or her legal representative, understands that during the Opt-out period, a Medicare Advantage plan may not by law make any payments to the Physician for any Medicare items and services furnished to the Beneficiary under this contract. Xxxxxxx X. Xxxxx, DO 1467779819 Name of Physician National Provider Identifier Contact: c/o Carah Medical Arts, 000 Xxx Xx, 0xx Xx, Xxxxxxxxxxxx, XX 00000; phone: 000-000-0000. Signature of Physician Date (MM/DD/YYYY) Name of Beneficiary Date of Birth (MM/DD/YYYY) Name of Legal Representative (if different from above) Relationship to Patient Member Signature of Beneficiary or Legal Representative Date (MM/DD/YYYY) 000 Xxx Xxxxxx, 0xx Xxxxx Xxxxxxxxxxxx, XX 00000 This authorization gives permission to release and disclose health information about the named individual to Carah Medical Arts. Patient Name: _ Date of Birth (MM/DD/YYYY): Please enter name and, if available, address of healthcare entity whom you authorize to disclose health information on the line below: is authorized to release and disclose the health information of the above named individual as described in this authorization: Carah Medical Arts, 000 Xxx Xxxxxx, 0xx Xxxxx, Xxxxxxxxxxxx, XX 00000, Phone: 000-000-0000, Fax: 000-000-0000. Substance abuse records (drug or alcohol) Yes ❑ No ❑ Initials Mental health records protected by the Mental Health Procedures Act Yes ❑ No ❑ Initials HIV/AIDS related information Yes ❑ No ❑ Initials I understand that I have the following rights: • Right not to sign. Refusal to sign will not affect my ability to obtain treatment at the clinic operated by Carah Medical Arts.

Beneficiary Obligations. 2.1 Beneficiary or his or her legal representative agrees, understands and expressly acknowledges the following: a. The Beneficiary or his or her legal representative acknowledges the Physicians have informed the Beneficiary, or his or her legal representative, accepts that the Physicians have opted out of the Medicare program effective on January 1, 2020 for a period of at least two (2) years and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act. b. The Beneficiary or his or her legal representative, accept full responsibility for payment of the charges Physicians charge for all services furnished by the Physician. Physicians. c. The Beneficiary, or his or her legal representative, understands that no payment will be provided by Medicare for items or services furnished by the Physician Physicians that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. . d. The Beneficiary, or his or her legal representative, understands that Medicare limits or any other Medicare reimbursement regulations do not apply to what the Physicians may be charged charge for items or services furnished by the Physician. Physicians. e. The Beneficiary, or his or her legal representative, agrees not to submit a claim, nor ask the Physician Physicians to submit a claim, to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare. . f. The Beneficiary, or his or her legal representative, Beneficiary acknowledges that he/she has read and sufficiently understands this written private contract contains sufficiently large print to ensure that the Beneficiary, or his or her legal representative, is able to read this contract. . g. The Beneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for their covered services, and that the Beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. . h. The Beneficiary, or his or her legal representative, understands that Medigap plans do not, and other other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. . i. The Beneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the Physician Physicians during a time when the Beneficiary requires emergency care services or urgent care services, except that the Physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § C.F.R & 405.440. . j. The Beneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the Beneficiary, or to his or her legal representative, before items or services have been furnished to the Beneficiary under the terms of this contract. . k. The Beneficiary, or his or her legal representative, understands acknowledges and agrees that during the Optopt-out period, a Medicare Advantage plan may not by law make any payments to the Physician Physicians for any Medicare items and services furnished to the Beneficiary under this contract. Xxxxxxx (Signature page follows) PHYSICIAN: Xxxx X. Xxxxx, DO 1467779819 Name of Physician National Provider Identifier Contact: c/o Carah Medical Arts, 000 Xxx Xx, 0xx Xx, Xxxxxxxxxxxx, XX 00000; phone: 000-000-0000. Signature of Physician Date (MM/DD/YYYY) Name of Beneficiary Date of Birth (MM/DD/YYYY) Name of Legal Representative (if different from above) Relationship to Patient Member Signature of Beneficiary or Legal Representative Date (MM/DD/YYYY) 000 Xxx Xxxxxx, 0xx Xxxxx Xxxxxxxxxxxx, XX 00000 This authorization gives permission to release and disclose health information about the named individual to Carah Medical Arts. Patient Name: _ Date of Birth (MM/DD/YYYY): Please enter name and, if available, address of healthcare entity whom you authorize to disclose health information on the line below: is authorized to release and disclose the health information of the above named individual as described in this authorization: Carah Medical Arts, 000 Xxx Xxxxxx, 0xx Xxxxx, Xxxxxxxxxxxx, XX 00000, Phone: 000-000-0000, Fax: 000-000-0000. Substance abuse records (drug or alcohol) Yes ❑ No ❑ Initials Mental health records protected by the Mental Health Procedures Act Yes ❑ No ❑ Initials HIV/AIDS related information Yes ❑ No ❑ Initials I understand that I have the following rights: • Right not to sign. Refusal to sign will not affect my ability to obtain treatment at the clinic operated by Carah Medical Arts.MD NPI:0000000000

Beneficiary Obligations. 2.1 Beneficiary or his or her legal representative agrees, understands and expressly acknowledges the following: a. The Beneficiary or his or her legal representative acknowledges the Physician has informed the Beneficiary, or his or her legal representative, that the Physician has opted out of the Medicare program effective on January 1, 2020 for a period of at least two (2) years and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act. b. The Beneficiary or his or her legal representative, accepts full responsibility for payment of the charges Physicians charge for all services furnished by the Physician. . c. The Beneficiary, or his or her legal representative, understands that no payment will be provided by Medicare for items or services furnished by the Physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. . d. The Beneficiary, or his or her legal representative, understands that Medicare limits or any other Medicare reimbursement regulations do not apply to what the Physician may be charged charge for items or services furnished by the Physician. . e. The Beneficiary, or his or her legal representative, agrees not to submit a claim, nor ask the Physician to submit a claim, to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare. . f. The Beneficiary, or his or her legal representative, Beneficiary acknowledges that he/she has read and sufficiently understands this written private contract contains sufficiently large print to ensure that the Beneficiary, or his or her legal representative, is able to read this contract. . g. The Beneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for their covered services, and that the Beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. . h. The Beneficiary, or his or her legal representative, understands that Medigap plans do not, and other other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. . i. The Beneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the Physician Physcian during a time when the Beneficiary requires emergency care services or urgent care services, except that the Physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § C.F.R & 405.440. . j. The Beneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the Beneficiary, or to his or her legal representative, before items or services have been furnished to the Beneficiary under the terms of this contract. . k. The Beneficiary, or his or her legal representative, understands acknowledges and agrees that during the Optopt-out period, a Medicare Advantage plan may not by law make any payments to the Physician for any Medicare medicare items and services furnished to the Beneficiary under this contract. Xxxxxxx X. Xxxxx, DO 1467779819 Name of Physician National Provider Identifier Contact: c/o Carah Medical Arts, 000 Xxx Xx, 0xx Xx, Xxxxxxxxxxxx, XX 00000; phone: 000-000-0000. Signature of Physician Date (MM/DD/YYYY) Name of Beneficiary Date of Birth (MM/DD/YYYY) Name of Legal Representative (if different from above) Relationship to Patient Member Signature of Beneficiary or Legal Representative Date (MM/DD/YYYY) 000 Xxx Xxxxxx, 0xx Xxxxx Xxxxxxxxxxxx, XX 00000 This authorization gives permission to release and disclose health information about the named individual to Carah Medical Arts. Patient Name: _ Date of Birth (MM/DD/YYYY): Please enter name and, if available, address of healthcare entity whom you authorize to disclose health information on the line below: is authorized to release and disclose the health information of the above named individual as described in this authorization: Carah Medical Arts, 000 Xxx Xxxxxx, 0xx Xxxxx, Xxxxxxxxxxxx, XX 00000, Phone: 000-000-0000, Fax: 000-000-0000. Substance abuse records (drug or alcohol) Yes ❑ No ❑ Initials Mental health records protected by the Mental Health Procedures Act Yes ❑ No ❑ Initials HIV/AIDS related information Yes ❑ No ❑ Initials I understand that I have the following rights: • Right not to sign. Refusal to sign will not affect my ability to obtain treatment at the clinic operated by Carah Medical Arts.

Beneficiary Obligations. The Beneficiarybeneficiary, or his or her legal representative, accepts full responsibility for payment of the charges physician's charge for all services furnished by the Physicianphysician. The Beneficiarybeneficiary, or his or her legal representative, understands that no payment will be provided by Medicare for items or services furnished by the Physician physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. The Beneficiarybeneficiary, or his or her legal representative, representative understands that Medicare limits or any other Medicare reimbursement regulations do not apply to what the physician may be charged charge for items or services furnished by the Physicianphysician. The Beneficiarybeneficiary, or his or her legal representative, agrees not to submit a claim, nor ask the Physician physician to submit a claim, claim to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare. The Beneficiary, or his or her legal representative, beneficiary acknowledges that this written private contract contains sufficiently large print to ensure that the Beneficiary, or his or her legal representative, beneficiary is able to read this contract. The Beneficiarybeneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for their covered services, and that the Beneficiary beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. The Beneficiarybeneficiary, or his or her legal representative, understands that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. The Beneficiarybeneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the Physician physician during a time when the Beneficiary beneficiary requires emergency care services or urgent care services, except that the Physician physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440. The Beneficiarybeneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the Beneficiarybeneficiary, or to his or his/her legal representative, before items or services have been furnished to the Beneficiary beneficiary under the terms of this contract. The Beneficiary, or his or her legal representative, understands that during the Opt-out period, a Medicare Advantage plan may not by law make any payments to the Physician for any Medicare items and services furnished to the Beneficiary under this contract. Xx Xxxxx Xxxxxxx X. Xxxxx, DO 1467779819 Name of Physician National Provider Identifier Contact: c/o Carah Medical Arts, 000 Xxx Xx, 0xx Xx, Xxxxxxxxxxxx, XX 00000; phone: 000-000-0000. Signature of Physician Date (MM/DD/YYYY) Name of Beneficiary Date of Birth (MM/DD/YYYY) Name of Legal Representative (if different from above) Relationship to Patient Member Signature of Beneficiary or Legal Representative Date (MM/DD/YYYY) 000 Xxx Xxxxxx, 0xx Xxxxx Xxxxxxxxxxxx, XX 00000 This authorization gives permission to release and disclose health information about the named individual to Carah Medical Arts. Patient Name: _ Date of Birth (MM/DD/YYYY): Please enter name and, if available, address of healthcare entity whom you authorize to disclose health information on the line below: is authorized to release and disclose the health information of the above named individual as described in this authorization: Carah Medical Arts, 000 Xxx Xxxxxx, 0xx Xxxxx, Xxxxxxxxxxxx, XX 00000, Phone: 000-000-0000, Fax: 000-000-0000. Substance abuse records (drug or alcohol) Yes ❑ No ❑ Initials Mental health records protected by the Mental Health Procedures Act Yes ❑ No ❑ Initials HIV/AIDS related information Yes ❑ No ❑ Initials I understand that I have the following rights: • Right not to sign. Refusal to sign will not affect my ability to obtain treatment at the clinic operated by Carah Medical Arts.printed)