Common use of FINANCIAL AGREEMENT Clause in Contracts

FINANCIAL AGREEMENT. I understand that there is no guarantee of reimbursement or payment from any insurance company or other payer. I understand this Agreement is a contract and that it obligates me to pay all charges for my treatment not paid by my insurer or any other payer source. I understand the Hospital has pre-determined the charges for certain procedures, supplies, and treatments, which these charges are listed in the Hospital’s Chargemaster, and these prices are incorporated by reference into this Contract. I acknowledge it may not be possible to state in advance which specific supplies and services will be part of my treatment. I acknowledge I have the right to receive an estimate of the facility’s average charge for treatment that are frequently performed on in-patient, outpatient, or surgical procedures. If I receive an estimate of charges, I acknowledge that the Hospital is acting in good faith by providing such an estimate. I acknowledge that any estimate is not binding and that the charges I am personally obligated to pay may be more than the estimated charge for my specific treatment. I acknowledge this Contract means I personally have full financial responsibility for, and agree to pay, all charges for the Hospital and of physicians rendering services not otherwise paid by my health insurance or other payer based upon the Hospital’s pre-determined Chargemaster rates. Estimated patient responsibility is due at the time of service or following the medical screening exam. Any remaining charges are due and payable upon receipt of the xxxx. I acknowledge and understand that any refund that I may be owed will first be applied to any outstanding balance, and the remainder will be forwarded to the address on file with the Hospital. If I do not have insurance or I cannot pay my xxxx, I may qualify for financial assistance. I understand that I may be required to submit documentation to determine my eligibility for financial assistance. I understand the hospital may request and use data from third parties such as credit reporting agencies in order to verify demographic data or evaluate financial options. If payment is not made within 180 days after receipt of the xxxx, a delinquent charge or interest at the maximum legal rate may be added. I agree to pay all legal expenses necessary for the collection of any debt or any action on this Contract. I hereby acknowledge and agree that the Hospital has not made any implied representations about the charges I am personally obligated to pay. I understand the charges I will be charged for my treatment are pre-determined rates based upon the Chargemaster in effect at the time of my treatment. I have agreed to pay the Hospital’s Chargemaster rates for the treatment I receive.

FINANCIAL AGREEMENT. I You are ultimately responsible for all charges. We understand that there is no guarantee of reimbursement or being a parent can be expensive. Please ask us about flexible payment from any insurance company or other payer. I understand this Agreement is a contract plans! Payment for services, including deductibles and that it obligates me to pay all charges for my treatment not paid by my insurer or any other payer source. I understand the Hospital has pre-determined the charges for certain procedurescopayments, supplies, and treatments, which these charges are listed in the Hospital’s Chargemaster, and these prices are incorporated by reference into this Contract. I acknowledge it may not be possible to state in advance which specific supplies and services will be part of my treatment. I acknowledge I have the right to receive an estimate of the facility’s average charge for treatment that are frequently performed on in-patient, outpatient, or surgical procedures. If I receive an estimate of charges, I acknowledge that the Hospital is acting in good faith by providing such an estimate. I acknowledge that any estimate is not binding and that the charges I am personally obligated to pay may be more than the estimated charge for my specific treatment. I acknowledge this Contract means I personally have full financial responsibility for, and agree to pay, all charges for the Hospital and of physicians rendering services not otherwise paid by my health insurance or other payer based upon the Hospital’s pre-determined Chargemaster rates. Estimated patient responsibility is due at the time of the service unless other arrangements have been made prior to treatment. Payments may be made using cash, check, or following credit cards. Iris Pediatric Dentistry accepts most insurance plans but is only in-network with some plans. The insurance contract is an agreement between you and the medical screening examinsurance company. Any remaining charges You are due and payable upon receipt of the xxxxultimately responsible for all charges. I acknowledge and understand We cannot guarantee that any refund that I may be owed will first be applied to any outstanding balance, and the remainder coverage estimated by your plan will be forwarded to the address on file with the Hospital. If I do not have insurance or I cannot pay my xxxxpaid once a claim is filed, I may qualify for financial assistance. I understand that I may be required to submit documentation to determine my eligibility for financial assistance. I understand the hospital may request and use data from third parties such as credit reporting agencies in order to verify demographic data maximize your benefits and because plans differ from carrier to carrier, and from policy to policy, our office may refer you to your carrier or evaluate financial optionsyou employer's benefits coordinator for assistance in understanding your plan. If payment It is not made within 180 days after receipt the responsibility of the xxxx, a delinquent charge patient or interest at the maximum legal rate may be added. I agree guardian to pay all legal expenses necessary for the collection of any debt or any action on this Contract. I hereby acknowledge and agree that the Hospital has not made any implied representations about the charges I am personally obligated to pay. I understand the charges I will be charged for my treatment benefits and limitations. We are pre-determined rates based upon happy to submit the Chargemaster in effect claims necessary to see that you receive your benefits, but we are only able to submit claims if all insurance information is provided to the office prior to treatment. Any plans not disclosed or unknown at the time of my treatmentservice will be the responsibility of the patient for claim submission and follow-up. I Please note that dental insurance is intended to cover some but not all dental care costs and not all services are covered by your plan. You are responsible for payment of all services regardless of the payable benefit. We have agreed to pay the Hospital’s Chargemaster rates updated our system and now keep a card on file for the convenience of our patients. As a courtesy we will collect only the estimated patient portion on the day of treatment, and claims will be submitted to your insurance company. Once the claim has been returned we will use the card on file for any charges that remain unpaid up to the total estimate listed on treatment I receiveestimates. If you would prefer to not keep a card on file, you have the option to pay-in-full for all treatment to be completed on the day of service and be reimbursed any overpayment once payment from your insurance company has been received. We would be happy to discuss our charges and how they relate to your particular situation. Please indicate your understanding and acceptance of these financial policies by signing below.

FINANCIAL AGREEMENT. I understand that there is no guarantee of reimbursement or payment from any insurance company or other payer. I understand this Agreement is a contract and that it obligates me to pay all charges for my treatment not paid by my insurer or any other payer source. I understand the Hospital has pre-determined the charges for certain procedures, supplies, and treatments, which these charges are listed in the Hospital’s Chargemaster, and these prices are incorporated by reference into this Contract. I acknowledge it may not be possible to state in advance which specific supplies and services will be part of my treatment. I acknowledge I have the right to receive an estimate of the facility’s average charge for treatment that are frequently performed on in-patient, outpatient, or surgical procedures. If I receive an estimate of charges, I acknowledge that the Hospital is acting in good faith by providing such an estimate. I acknowledge that any estimate is not binding and that the charges I am personally obligated to pay may be more than the estimated charge for my specific treatment. I acknowledge this Contract means I personally have full financial responsibility for, and agree to pay, all charges for the Hospital and of physicians rendering services not otherwise paid by my health insurance or other payer based upon the Hospital’s pre-determined Chargemaster rates. Estimated patient responsibility is due at the time of service or following the medical screening exam. Any remaining charges are due and payable upon receipt of the xxxx. I acknowledge and understand that any refund that I may be owed will first be applied to any outstanding balance, and the remainder will be forwarded to the address on file with the Hospital. If I do not have insurance or I cannot pay my xxxx, I may qualify for financial assistance. I understand that I may be required to submit documentation to determine my eligibility for financial assistance. I understand the hospital may request and use data from third parties such as credit reporting agencies in order to verify demographic data or evaluate financial options. If payment is not made within 180 days after receipt of the xxxx, a delinquent charge or interest at the maximum legal rate may be addedservice. I agree to pay Kind Medical Group for all legal expenses necessary charges for the collection healthcare services and professional services provided to me by physicians and other healthcare professionals. Acceptable forms of any debt or any action on this Contractpayment include Cash, Visa, MasterCard, Discover, and American Express. I hereby acknowledge and agree that the Hospital has not made any implied representations about the charges If I am personally obligated a non-insured patient, I agree to pay. I understand the charges I will be charged pay for my treatment are pre-determined rates based upon the Chargemaster visit in effect full at the time of service. If Kind Medical Group is a participating provider with my treatmentinsurance company, I understand that my co-pay, coinsurance, deductible, and/or any outstanding balances are due at the time of service. I have agreed understand that my insurance policy is a contract between myself and my insurance company, Kind Medical Group is not involved. In order for Kind Medical Group to file claims and accept payments from my insurance carrier, I understand that I must present current insurance information at each visit and that Kind Medical Group will need to verify my health insurance coverage. In the event that Kind Medical Group is not able to verify my insurance eligibility and benefits before my visit, I agree to pay for my visit in full at the Hospital’s Chargemaster rates time of service. A refund will be issued if my insurance pays for the treatment visit. I receive.also understand that I am financially responsible for any services not covered by my insurance company. When my spouse or a financial guarantor signs this agreement, the spouse or the financial guarantor shall be jointly and individually liable with me. Should my account(s) be referred to an attorney or a collection agency for the collection, the undersigned shall pay the actual attorney’s fees (including costs) and collections expenses incurred in addition to the other amounts due. Unpaid accounts referred to outside agencies for collection shall bear interest at the current rate per year from the date of referral. INSURANCE AUTHORIZATION AND RELEASE: I request the payment of authorized benefits, including Medicare, and any other government sponsored program, private insurance, and any other health plans to be made to Kind Medical Group for any services furnished by that provider. To the extent necessary to coordinate my health care or determine liability for payment and to obtain reimbursement for services rendered, I authorize Kind Medical Group to disclose portions of or all of my records, including my medical records to any person or corporation which is or may be liable for all or any portion of Kind Medical Group charges, including but not limited to insurance companies, health care service plans, governmental agencies, or worker’s compensation carriers. I authorize Kind Medical Group to act as my agent to help me obtain any required

FINANCIAL AGREEMENT. I understand that there is no guarantee of reimbursement or payment from any insurance company or other payerthe undersigned patient, assign directly to Physiatry and Rehabilitation Associates, LLC, all benefits, otherwise payable to me for services rendered. I understand also authorize this Agreement is a contract and that it obligates me office to pay release all charges for my treatment not paid by my insurer or any other payer sourceinformation necessary to secure the payment of benefits. I understand authorize the Hospital has pre-determined the charges for certain procedures, supplies, and treatments, which these charges are listed in the Hospital’s Chargemaster, and these prices are incorporated by reference into use of this Contract. I acknowledge it may not be possible to state in advance which specific supplies and services will be part of my treatment. I acknowledge I have the right to receive an estimate of the facility’s average charge for treatment that are frequently performed signature on in-patient, outpatient, all insurance submissions whether manual or surgical procedures. If I receive an estimate of charges, I acknowledge that the Hospital is acting in good faith by providing such an estimateelectronic. I acknowledge that any estimate is not binding and that the charges I am personally obligated to pay may be more than the estimated charge for my specific treatment. I acknowledge this Contract means I personally have full financial responsibility for, and agree to pay, all charges for the Hospital and of physicians rendering services not otherwise paid by my health insurance or other payer based upon the Hospital’s pre-determined Chargemaster rates. Estimated patient responsibility payment is due at the time of service or following the medical screening exam. Any remaining charges are due and payable upon receipt of the xxxxtreatment. I acknowledge and understand that any refund that I accept full financial responsibility for all charges not covered by insurance. Certain tests may be owed will first be applied to any outstanding balance, ordered by the doctor(s) of Physiatry and the remainder will be forwarded to the address on file with the Hospital. If I do not have insurance or I cannot pay my xxxx, I may qualify for financial assistance. I understand that I may be required to submit documentation to determine my eligibility for financial assistance. I understand the hospital may request and use data from third parties such as credit reporting agencies in order to verify demographic data or evaluate financial options. If payment is not made within 180 days after receipt of the xxxx, a delinquent charge or interest at the maximum legal rate may be addedRehabilitation Associates LLC. I agree to pay be financially responsible for those services should they be considered “non-covered” or not medically indicated by my insurance company. A Pain Perception Test (PPT) is ordered on all legal expenses necessary for new patients. This is comprised of a series of questions including demographical, medical, and psychological data. If my treatment is involved with a work related injury and PRA is to file Xxxxxxx’x Compensation claims on my behalf, I authorize the collection doctors and staff to discuss plan of treatment, care and appointment information with claim payers and/or case workers. If at any debt point during or after my treatment in the clinic I should desire a copy of my medical records, there will be a minimum fee of $15.00. After the first 25 pages, there will be a fee of $0.50/page. Payment must be received in advance along with a XXXXX compliant release form and an original signature. Should I desire to have them mailed, I must provide PRA with a self-addressed stamped envelope. The preparation may take up to four weeks. For any action on this Contract. I hereby acknowledge form that PRS is asked and agree that the Hospital has not made any implied representations about the charges I am personally obligated to pay. I understand the charges I fill out, there will be charged for my treatment are pre-determined rates based upon a minimum fee of $25.00 payable prior to completion of the Chargemaster in effect at the time of my treatmentform. I have agreed This fee will be billed directly to pay the Hospital’s Chargemaster rates for the treatment I receive.me and will not be filed with any insurance company or other third party. PRINTED Patient/Authorized Rep Name PRIMARY INSURANCE COMPANY SECONDARY INSURANCE SIGNATURE OF PATIENT/REP EMPLOYER Emergency Contact (Name & Phone #) TODAY’S DATE: / / mo / day / yr

FINANCIAL AGREEMENT. CANCELLATION– 72 hour notice must be provided in the event you cannot keep a Surgery appointment. Should you not provide this notice a cancellation fee of $100.00 may then be added to your account. PRIVATE INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS/INFORMATION RELEASE: I, the undersigned, authorize payment of medical benefits to Upper Valley Surgery Center PLLC for any services furnished. I understand that there is no guarantee I am financially responsible for any amount not covered by my contract. I also authorize any holder of reimbursement or payment from any medical information about me to release to my insurance company (or other payertheir agent) information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits. MEDICARE – Upper Valley Surgery Center will submit claims to Medicare. The patient will be responsible for the deductible and the 20% co-insurance, which can be billed to a secondary insurance if you have one. MEDICARE LIFETIME SIGNATURE ON FILE: I, the undersigned request that payment of authorized Medicare benefits be made on my behalf to Upper Valley Surgery Center PLLC for any services furnished to me. I understand this Agreement authorize any holder of medical information about me to release to the CMS (and its agents) any information to determine these benefits payable for related services. This information will be used for the purpose of evaluating and administering claims of benefits. MEDICAID: Upper Valley Surgery is a contract and that it obligates me Medicaid Provider. Any charges not covered by Medicaid may be your responsibility to pay. CO-PAYMENTS – Please be prepared to pay all charges for my treatment the co-pay at your visit. By law we MUST collect your carrier designated co-pay and it is expected at the time of service. Should you not paid by my insurer or any other payer source. I understand the Hospital has pre-determined the charges for certain procedures, supplies, and treatments, which these charges are listed in the Hospital’s Chargemaster, and these prices are incorporated by reference into this Contract. I acknowledge it may not be possible to state in advance which specific supplies and services will be part of my treatment. I acknowledge I have the right to receive an estimate of the facility’s average charge for treatment that are frequently performed on in-patient, outpatient, or surgical procedures. If I receive an estimate of charges, I acknowledge that the Hospital is acting in good faith by providing such an estimate. I acknowledge that any estimate is not binding and that the charges I am personally obligated to pay may be more than the estimated charge for my specific treatment. I acknowledge this Contract means I personally have full financial responsibility for, and agree to pay, all charges for the Hospital and of physicians rendering services not otherwise paid by my health insurance or other payer based upon the Hospital’s pre-determined Chargemaster rates. Estimated patient responsibility is due at the time of service or following the medical screening exam. Any remaining charges are due and payable upon receipt we subsequently send you a statement, an administrative fee of the xxxx. I acknowledge and understand that any refund that I $20 may be owed will first be applied added to any outstanding balanceyour account. SELF-PAY PATIENTS – Payment is expected prior to service. WE ACCEPT CASH, and the remainder will be forwarded to the address on file with the HospitalCHECKS, MASTERCARD, VISA, OR DISCOVER CARD. If I do not have insurance or I cannot pay my xxxx, I may qualify for financial assistance. I understand that I may be required to submit documentation to determine my eligibility for financial assistance. I understand the hospital may request and use data from third parties such as credit reporting agencies in order to verify demographic data or evaluate financial options. If payment your check is not made within 180 days after receipt of the xxxx, a delinquent charge or interest at the maximum legal rate may be added. I agree to pay all legal expenses necessary for the collection of any debt or any action on this Contract. I hereby acknowledge and agree that the Hospital has not made any implied representations about the charges I am personally obligated to pay. I understand the charges I will be charged for my treatment are pre-determined rates based upon the Chargemaster in effect at the time of my treatment. I have agreed to pay the Hospital’s Chargemaster rates for the treatment I receive.returned

FINANCIAL AGREEMENT. I understand that there is no guarantee of reimbursement or payment from any insurance company or other payer. I understand this Agreement is a contract and that it obligates me to pay all charges for my treatment not paid by my insurer or any other payer source. I understand the Hospital has pre-determined the charges for certain procedures, supplies, and treatments, which these charges are listed in the Hospital’s Chargemaster, and these prices are incorporated by reference into this Contract. I acknowledge it may not be possible to state in advance which specific supplies and services will be part of my treatment. I acknowledge I have the right to receive an estimate of the facility’s average charge for treatment that are frequently performed on in-patient, outpatient, or surgical procedures. If I receive an estimate of charges, I acknowledge that the Hospital is acting in good faith by providing such an estimate. I acknowledge that any estimate is not binding and that the charges I am personally obligated to pay may be more than the estimated charge for my specific treatment. I acknowledge this Contract means I personally have full financial responsibility for, and agree to pay, all charges for the Hospital and of physicians rendering services not otherwise paid by my health insurance or other payer based upon the Hospital’s pre-determined Chargemaster rates. Estimated patient responsibility payment is due at the time of service or following the medical screening exam. Any remaining charges treatment unless other arrangements are due and payable upon receipt of the xxxxmade. I acknowledge that all financially responsible parties are to be present for all treatment planning and financial estimates. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor/child. I accept full financial responsibility for all charges not covered by insurance. In the event my account balance remains unpaid in excess of 90 days, I understand that any refund that I may be owed will first be applied to any outstanding balance, and the remainder my account will be forwarded turned over to the address on file a collections agency. I accept full responsibility for all administrative and legal fees associated with the Hospital. If I do not have insurance or I cannot pay my xxxx, I may qualify for financial assistancecollections process. I understand that I may be required to submit documentation to determine my eligibility for financial assistance. I understand the hospital may request Palm Valley Family Dentistry has a broken appointment policy and use data from third parties such as credit reporting agencies in order to verify demographic data or evaluate financial options. If payment is not made within 180 days after receipt of the xxxx, a delinquent charge or interest at the maximum legal rate may be added. I agree to pay all legal expenses necessary for the collection of any debt or any action on this Contract. I hereby acknowledge and agree that the Hospital has not made any implied representations about the charges I am personally obligated to pay. I understand the charges I will be charged $40 unless I notify the office at least 24 hours in advance for a cancelled appointment. I understand that personal checks are accepted as forms of payment. I also understand that if a check is returned due to insufficient funds, I will be assessed a $50 fee on my account. Signature Date I, the undersigned, acknowledge receipt of a copy of the currently effective Notice of Privacy Practices for the office of Palm Valley Family Dentistry as of today’s date. A copy of the signed, dated acknowledgement shall be as effective as the original. Signed Date Printed name I hereby authorize Palm Valley Family dentistry to discuss my dental diagnosis, dental treatment, appointments, and account information with the below named person(s). If you have any questions about this form, please contact the privacy officer, Dr. Xxxxx Xxxxx. Office use only: As privacy officer, I attempted to obtain the patient’s (or representative’s) signature on this acknowledgement but did not because: Signature: Privacy officer You the patient have the right to accept or reject dental treatment are pre-determined rates based upon recommended by your dentist. Prior to consenting to treatment, you should carefully consider the Chargemaster in effect at anticipated benefits and commonly known risks of the time recommended procedure, alternative treatments, or the option of my no treatment. I have agreed By consenting, you are acknowledging your willingness to pay accept known risks and complications, no matter how slight the Hospitalprobability of occurrence. It is very important that you follow your dentist’s Chargemaster rates advice and recommendations regarding medication, pre- and post- treatment instruction, referrals to other dentists or specialists and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. The patient is an important part of the treatment I receive.team. In addition, complying with the instructions given to you by this office, it is important to report any problems or complications you experience so they can be addressed. Certain heart conditions may create a risk of serious or fatal complications. If you (or a minor patient) have a heart condition, adviser your dentist immediately so that precautions can be taken or your physician consulted, if necessary. If you are a woman on birth control medication, you must consider the fact that antibiotics might make oral birth control less effective. Please consult with you physician before relying on oral birth control medication if you dentist prescribes, or if you are taking antibiotics. As with all surgery, there are commonly known risks and potential complications associated with dental treatment. No one can guarantee the success of the recommended treatment, or that you will not experience a complication or less than optimal result. Even though many of these complications are rare, they can and do occur occasionally. Some of the more commonly know risks and complications of treatment include but are not limited to:

FINANCIAL AGREEMENT. I understand that there is no guarantee of reimbursement or payment from any insurance company or other payer. I understand this Agreement is a contract and that it obligates me to pay all charges for my treatment not paid by my insurer or any other payer source. I understand the Hospital has pre-determined the charges for certain procedures, supplies, and treatments, which these charges are listed in the Hospital’s Chargemaster, and these prices are incorporated by reference into this Contract. I acknowledge it may not be possible to state in advance which specific supplies and services will be part of my treatment. I acknowledge I have the right to receive an estimate of the facility’s average charge for treatment that are frequently performed on in-patient, outpatient, or surgical procedures. If I receive an estimate of charges, I acknowledge that the Hospital is acting in good faith by providing such an estimate. I acknowledge that any estimate is not binding and that the charges I am personally obligated to pay may be more than the estimated charge for my specific treatment. I acknowledge this Contract means I personally have full financial responsibility for, and agree to pay, all charges for the Hospital and of physicians rendering services not otherwise paid by my health insurance or other payer based upon the Hospital’s pre-determined Chargemaster rates. Estimated patient responsibility is due at the time of service or following the medical screening exam. Any remaining charges are due and payable upon receipt of the xxxx. I acknowledge and understand that any refund that I may be owed will first be applied to any outstanding balance, and the remainder will be forwarded to the address on file with the Hospital. If I do not have insurance or I cannot pay my xxxx, I may qualify for financial assistance. I understand that I may be required to submit documentation to determine my eligibility for financial assistance. I understand the hospital may request and use data from third parties such as credit reporting agencies in order to verify demographic data or evaluate financial options. If payment is not made within 180 days after receipt of the xxxx, a delinquent charge or interest at the maximum legal rate may be addedservice. I agree to pay Xxxxxxxxx Prompt Care for all legal expenses necessary charges for the collection healthcare services and professional services provided to me by physicians and other healthcare professionals. Acceptable forms of any debt or any action on this Contractpayment include Cash, Visa, MasterCard, Discover, and American Express. I hereby acknowledge and agree that the Hospital has not made any implied representations about the charges If I am personally obligated a non-insured patient, I agree to pay. I understand the charges I will be charged pay for my treatment are pre-determined rates based upon the Chargemaster visit in effect full at the time of service. If Effingham Prompt Care is a participating provider with my treatmentinsurance company, I understand that my co-pay, coinsurance, deductible, and/or any outstanding balances are due at the time of service. I have agreed understand that my insurance policy is a contract between myself and my insurance company. In order for Effingham Prompt Care to file claims and accept payments from my insurance carrier, I understand that I must present current insurance information at each visit and that Effingham Prompt Care will need to verify my health insurance coverage. In the event that Xxxxxxxxx Prompt Care is not able to verify my insurance eligibility and benefits before my visit, I agree to pay for my visit in full at the Hospital’s Chargemaster rates time of service. A refund will be issued if my insurance pays for the treatment visit. I receivealso understand that I am financially responsible for any services not covered by my insurance company. When my spouse or a financial guarantor signs this agreement, the spouse or the financial guarantor shall be jointly and individual liable with me. Should my account(s) be referred to an attorney or a collection agency for the collection, the undersigned shall pay the actual attorney’s fees (including costs) and collections expenses incurred in addition to the other amounts due. Unpaid accounts referred to outside agencies for collection shall bear interest at the current rate per year from the date of referral. Insurance Authorization and Release: I request the payment of authorized benefits, including Medicare, and any other government sponsored program, private insurance, and any other health plans to be made to Effingham Prompt Care for any services furnished by that provider. To the extent necessary to coordinate my health care or determine liability for payment and to obtain reimbursement for services rendered, I authorize Effingham Prompt Care to disclose portions of or all of my records, including my medical records to any person or corporation which is or may be liable for all or any portion of Effingham Prompt Care charges, including but not limited to insurance companies, health care service plans, governmental agencies, or worker’s compensation carriers. I authorize Effingham Prompt Care to act as my agent to help me obtain any required pre-certification as well as acting as my agent to help me obtain payment from my insurance companies. I authorize my insurance companies to give Effingham Prompt Care any information required to fulfill this function. This will remain in effect until revoked in writing. A photocopy of this assignment and release is to be considered as valid as the original. Release of Medical Information: I hereby authorize Effingham Prompt Care to release any information in my chart to any practitioner, doctor, hospital, or medical institution to which I may be referred to assist in my care. Additionally, I authorize Effingham Prompt Care to provide a copy of my medical records to my Primary Care Physician (PCP) to allow for continuity of care. Notice of Privacy Practices: By signing this form, you acknowledge receipt of the “Notice Of Privacy Practices” of Effingham Prompt Care. Our “Notice of Privacy Practices” provides information about how we may use and disclose your protected health information. We encourage you to read it in full. Our “Notice of Privacy Practices” is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting Effingham Prompt Care. In-House Pharmacy: I understand that, for my convenience, Effingham Prompt Care can dispense some prescription medications necessary to treat my medical condition(s). I understand that my insurance will not be billed for medications dispensed and that my pharmacy benefits DO NOT apply to this service. Any medication(s) dispensed in the office are my responsibility and are an additional charge to my office visit charge. I also understand that if I prefer to use an outside pharmacy, a prescription can be provided to me at no additional charge.

FINANCIAL AGREEMENT. In consideration of Methodist Health System furnishing services and supplies to the above named patient, I agree to pay Methodist Health System, its agents and assigns, all sums of money which shall become due on the account of the above named patient with Methodist Health System in accordance with its regular rates and terms. I understand that there is no guarantee insurance will not pay for the total cost of reimbursement or payment from a suite and I agree to pay any charges toward the cost of a suite that insurance company or other payerdoes not pay. I understand this Agreement is a contract and that it obligates me to pay all charges for my treatment not paid by my insurer or any other payer source. I understand the Hospital has pre-determined the charges for certain procedures, supplies, and treatments, which these charges are listed in the Hospital’s Chargemaster, and these prices are incorporated by reference into this Contract. I acknowledge it may not be possible to state in advance which specific supplies and services will be part of my treatment. I acknowledge I have the right by Texas law to receive an estimate itemized statement of billed services within 30 days of my discharge and before receiving collection activity from the facility’s average charge for treatment that are frequently performed hospital. Methodist Health System maintains certain policies related to billing and collections on our website at xxxxxxxxxxxxxxxxxxxxx.xxx under the section Patients and Visitors, then select Financial Assistance. For questions related to billing or payment after discharge, please contact our customer service department at (000) 000-0000. ______ By opting in-patient, outpatient, or surgical procedures. If I receive an estimate of charges, I acknowledge that the Hospital is acting in good faith by providing such an estimateagree to receive itemized statements electronically through my health care portal, MyChart (initial) and all future itemized statements will be provided electronically. I acknowledge understand that any estimate is itemized statements ______ are available in MyChart no later than 4 days from the date of discharge. ______ By opting out, I do not binding and that the charges I am personally obligated to pay may be more than the estimated charge for my specific treatment. I acknowledge this Contract means I personally have full financial responsibility for, and agree to pay, all charges for the Hospital and of physicians rendering services not otherwise paid by receive itemized statements electronically through my health insurance or other payer based upon the Hospital’s pre-determined Chargemaster ratescare portal, (initial) MyChart. Estimated patient responsibility is due at the time of service or following the medical screening exam. Any remaining charges are due and payable upon receipt of the xxxx. I acknowledge and understand that any refund that I may be owed will first be applied to any outstanding balance, and the remainder Itemized statements will be forwarded mailed to the address on file no later than 14 days from the date of ______ discharge. I understand and agree that the account is due upon discharge with the Hospitalallowances made for insurance coverage approved and verified prior to discharge. If I do Methodist Health System will not have insurance or I cannot pay my xxxx, I may qualify for financial assistanceextend credit. I understand that although the patient and others may also be responsible for paying this account by virtue of an express or implied agreement, or otherwise, I shall be responsible to pay the entire account, and I further understand that this agreement in no way relieves any such other party of any obligation to pay this account. I further understand that should this account become delinquent and it becomes necessary for the account to be referred to any attorney or collection agency for collection or suit, I as the designated responsible party shall pay the reasonable attorney fees or collection expenses. All accounts are due and payable in Dallas, Dallas County, Texas. Consent for Wireless Calls, Text Messaging, and Email: If at any time I provide a wireless telephone number at which I may be required contacted, I consent to submit documentation to determine receive calls and/or texts (including autodialed calls and prerecorded messages) at that wireless number from the hospital, agents, and independent contractors, including servicers and collection agencies regarding the hospitalization, the services rendered, or my eligibility for related financial assistanceobligations. I understand consent to receive information about Methodist Health System events such as: upcoming health fairs, health and wellness updates, new locations and services via email and mail. In addition, the hospital Methodist Health System patient portal uses your email as the initial access to the portal. Authorization to release information: I authorize Methodist Health System to furnish requested information from the patient's medical and other records to (1) any insurance company or third party payor for the purpose of obtaining payment on the account of Methodist Health System, (2) any other person(s) or entities financially responsible for the patient's care or treatment, and (3) representatives of local, state, and federal agencies in accordance with law. Such information may request and use data from third parties include, but is not limited to, information concerning communicable diseases such as credit reporting agencies in order to verify demographic data Acquired Immune Deficiency Syndrome (AIDS). I authorize the release of information from or evaluate financial options. If payment is not made within 180 days after receipt the review of the xxxxpatient's record for purposes of conducting any medical audits, a delinquent charge utilization reviews, or interest at quality assurance reviews. I authorize Methodist Health System to release information or copies of the maximum legal rate patient's medical record to any referring physician or to any skilled nursing facility or other health care facility to which the patient may be added. I agree to pay all legal expenses necessary for the collection of any debt or any action on this Contract. I hereby acknowledge and agree that the Hospital has not made any implied representations about the charges I am personally obligated to pay. I understand the charges I will be charged for my treatment are pre-determined rates based upon the Chargemaster in effect at the time of my treatment. I have agreed to pay the Hospital’s Chargemaster rates for the treatment I receivetransferred.