Common use of Patient Rights and Responsibilities Clause in Contracts

Patient Rights and Responsibilities. A. I understand that pre-existing medical conditions do not disqualify me from enrolling into Evolve and that I have a right to know my treatment options and actively participate in my health care decisions. B. I understand that I have the right to a fair, expedient and objective review of any complaint I may have against Evolve and a Practitioner and that I will submit my concerns, suggestions, and patient feedback to xxxx@xxx0xx.xxx. C. I understand that in the event of a life-threatening medical condition, I should always call 911 or proceed to the nearest emergency department. I also understand that the costs of urgent care services not rendered by Evolve are not included in Evolve’s monthly membership fees or otherwise. D. I understand that Practitioners are available for telephone consultations in the event of an urgent medical matter, but I will call 911 or proceed to the nearest emergency department if immediate medical attention and/or treatment is required. Patient Name: _ _ Patient Signature: _ __ _Date: _ Signature: _Date: Xxxxxxx X. Xxxxxxxx, MD Signature of Parent/Guardian: _Date: Please note: Evolve makes every effort to minimize lab costs for our members! Covid PCR lab billing is done by the lab processing your sample and it is not within our ability to control this cost. Our member cost for lab processing of PAP smears is also steeply discounted. PAP alone is $30 for our members (average national price is $88) and PAP with HPV is $87 for our members (average national price is $129). Women’s health can be very expensive if paying out-of-pocket. In addition to the fee for the lab (PAP+HPV=$129), you can expect to pay $65 to $125 for the visit PLUS $90 to $360 for the Pelvic Exam. • CBC (complete blood count) • CMP (comprehensive metabolic panel) • Lipid analysis • TSH/T4 (thyroid stimulating hormone and thyroid hormone) • PSA (prostate specific antigen) for men only

Patient Rights and Responsibilities. A. I understand that pre-existing medical conditions do not disqualify me from enrolling into Evolve IHNC and that I have a right to know my treatment options and actively participate in my health care healthcare decisions. B. I understand that I have the right to a fair, expedient expedient, and objective review of any complaint I may have against Evolve IHNC and a Practitioner and that I will submit my concerns, suggestions, suggestions and patient feedback to xxxx@xxx0xx.xxxxxxx@x-xxx.xxx. C. I understand that in the event of a life-threatening medical condition, I should always call 911 or proceed to the nearest emergency department. I also understand that the costs of urgent care services not rendered by Evolve IHNC are not included in EvolveIHNC’s monthly membership fees or otherwise.. Patient Signature: Date: Signature: Date: D. I understand that Practitioners Practitioner are available for telephone consultations in the event of an urgent medical matter, but I will call 911 or proceed to the nearest emergency department if immediate medical attention and/or treatment is required. If the Patient Nameis a minor, the Patient’s parent or legal guardian must sign below indicating the parent or guardian’s acceptance of the above terms and agreement to pay the Membership Fee on behalf of the Patient: _ _ Patient Signature: _ __ _Date: _ Signature: _Date: Xxxxxxx X. Xxxxxxxx, MD Signature of Parent/Guardian: _Date: Please note: Evolve makes every effort to minimize lab costs for our members! Covid PCR lab billing is done by the lab processing your sample and it is not within our ability to control this cost. Our member cost for lab processing of PAP smears is also steeply discounted. PAP alone is $30 for our members FECAL OCCULT BLOOD, STOOL GLUCOSE, FINGERSTICK, BLOOD HBA1C (average national price is $88) and PAP with HPV is $87 for our members (average national price is $129). Women’s health can be very expensive if paying out-of-pocket. In addition to the fee for the lab (PAP+HPV=$129HEMOGLOBIN A1C), you can expect to pay $65 to $125 for FINGERSTICK, HEMOGLOBIN (HB), FINGERSTICK, BLOOD MONONUCLEOSIS, HETEROPHILE AB, BLOOD PREGNANCY TEST, URINE RAPID FLU (A+B) RAPID STREP GROUP A, THROAT RESPIRATORY SYNCYTIAL VIRUS AG, QL, IF, NASOPHARYNX URINALYSIS, DIPSTICK VISUAL ACUITY* • X-Rays • Labs sent out of the visit PLUS $90 to $360 for the Pelvic Exam. office: clinic staff will notify estimated cost of external xxx xxxxxxxx • CBC (complete blood count) • CMP (comprehensive metabolic panel) • Lipid analysis • TSH/T4 (thyroid stimulating hormone and thyroid hormone) • PSA (prostate specific antigen) for men onlyAny specialty care visit

Patient Rights and Responsibilities. A. I understand that pre-existing medical conditions do not disqualify me from enrolling into Evolve and that I have a right to know my treatment options and actively participate in my health care healthcare decisions. B. I understand that I have the right to a fair, expedient and objective review of any complaint I may have against Evolve and a Practitioner and that I will submit my concerns, suggestions, suggestions and patient feedback to xxxx@xxx0xx.xxx. C. I understand that in the event of a life-threatening medical condition, I should always call 911 or proceed to the nearest emergency department. I also understand that the costs of urgent care services not rendered by Evolve are is not included in Evolve’s monthly membership fees or otherwise. D. I understand that Practitioners are available for telephone consultations in the event of an urgent medical matter, but I will call 911 or proceed to the nearest emergency department if immediate medical attention and/or treatment is required. Patient Name: _ _ Patient Signature: _ __ _Date: _ Signature: _Date: Xxxxxxx X. Xxxxxxxx, MD Signature of Parent/Guardian: _Date: _ Please note: Evolve makes every effort to minimize lab costs for our members! Covid PCR lab billing is done by the lab processing your sample and it is not within our ability to control this cost. Our member members cost for lab processing of PAP smears is also steeply discounted. PAP alone Pap along is $30 for our members (average national price is $88) and PAP with HPV is $87 for our members (average national price is $129). Women’s health can be very expensive if paying out-of-pocket. In addition to the fee for the lab (PAP+HPV=$129), you can expect to pay $65 to $125 for the visit PLUS $90 to $360 for the Pelvic Exam. • CBC (complete blood count) • CMP (comprehensive metabolic panel) • Lipid analysis • TSH/T4 (thyroid stimulating hormone and thyroid hormone) • PSA (prostate specific antigenProstate Specific Antigen) for men only

Patient Rights and Responsibilities. A. I understand that pre-existing medical conditions do not disqualify me from enrolling into Evolve and that I have a right to know my treatment options and actively participate in my health care healthcare decisions. B. I understand that I have the right to a fair, expedient and objective review of any complaint I may have against Evolve and a Practitioner and that I will submit my concerns, suggestions, suggestions and patient feedback to xxxx@xxx0xx.xxx. C. I understand that in the event of a life-threatening medical condition, I should always call 911 or proceed to the nearest emergency department. I also understand that the costs of urgent care services not rendered by Evolve are is not included in Evolve’s monthly membership fees or otherwise. D. I understand that Practitioners are available for telephone consultations in the event of an urgent medical matter, but I will call 911 or proceed to the nearest emergency department if immediate medical attention and/or treatment is required. Patient Name: _ _ Patient Signature: _ __ _Date: _ SignatureEvolve Direct Primary Care: _DateSigned by: Xxxxxxx X. Xxxxxxxx, MD Signature: Date: If the Patient is a minor, the Patient’s parent or legal guardian must sign below indicating the parent or guardian’s acceptance of the above terms and agreement to pay the Membership Fee on behalf of the Patient: Name of Parent or Legal Guardian: Signature of Parent/Parent or Legal Guardian: _Date: Please noteMEDICARE OPT-OUT AND LIST OF PRACTITIONERS‌ I AGREE, UNDERSTAND AND EXPRESSLY ACKNOWLEDGE THE FOLLOWING: • The Practitioners listed below (the “Practitioners”) have all opted out of the Medicare program effective on dates indicated after their names for a period of at least two years. • Neither Evolve makes every effort nor any Practitioner is involuntarily excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act. • I accept full responsibility for payment of Evolve’s and Practitioners’ charges for all items and services furnished to minimize lab costs me by Evolve. • Medicare fee limitations do not apply to what Evolve and the Practitioners may charge for our members! Covid PCR lab billing is done by the lab processing your sample and it is items or services they provide to me. • I will not within our ability to control this cost. Our member cost for lab processing of PAP smears is also steeply discounted. PAP alone is $30 for our members submit a claim (average national price is $88or request that Evolve or any Practitioner submit a claim) and PAP with HPV is $87 for our members (average national price is $129). Women’s health can be very expensive if paying out-of-pocket. In addition to the fee Medicare program for payment for any items or services provided to me by Evolve or any Practitioner, even if the lab (PAP+HPV=$129)items or services are covered by Medicare Part B. • Neither Evolve nor any Practitioner will submit a Medicare claim for items or services they furnish to me, you can expect to pay $65 to $125 and no Medicare reimbursement will be provided for the visit PLUS $90 to $360 for the Pelvic Examsuch items or services. • CBC Medicare payment will not be made for any items or services provided to me by Evolve or any Practitioner even if those items or services would have otherwise been covered by Medicare if I had not signed this Patient Agreement and this Attachment B, and a proper Medicare claim had been submitted. • I enter into this Patient Agreement with the knowledge that I have the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that I am not compelled to enter into private contracts that apply to other Medicare-covered items and services furnished by other physicians or practitioners who have not opted out of Medicare. • Medigap plans do not provide payment or reimbursement for items and services (such as any Services provided to me by Evolve or the Practitioners) not paid for by Medicare, and other supplemental plans may likewise deny payment or reimbursement for such items and services. • I am not currently in an emergency or urgent health care situation, and do not currently require emergency care or urgent health care services. • A copy of this Patient Agreement with this Attachment B has been provided to me. Patient Name: Patient Signature: Date: _ Xxxxxxx Xxxxxxxx, M.D. Primary care July 1, 2014 Xxxxx Xxxxx, MSN, FNP-C Primary care October 1, 2018 Xxxxx Xxxxx, CRNP Primary Care January 1, 2022 Xxxxx Xxxxxx, CRNP Primary Care January 1, 2022 Schedule your payments to be automatically charged to your credit card. Just complete blood count) • CMP (comprehensive metabolic panel) • Lipid analysis • TSH/T4 (thyroid stimulating hormone and thyroid hormone) • PSA (prostate specific antigen) for men onlysign this form to get started!

Patient Rights and Responsibilities. A. I understand that pre-existing medical conditions do not disqualify me from enrolling into Evolve and that I have a right to know my treatment options and actively participate in my health care healthcare decisions. B. I understand that I have the right to a fair, expedient and objective review of any complaint I may have against Evolve and a Practitioner and that I will submit my concerns, suggestions, suggestions and patient feedback to xxxx@xxx0xx.xxx. C. I understand that in the event of a life-threatening medical condition, I should always call 911 or proceed to the nearest emergency department. I also understand that the costs of urgent care services not rendered by Evolve are is not included in Evolve’s monthly membership fees or otherwise. D. I understand that Practitioners are available for telephone consultations in the event of an urgent medical matter, but I will call 911 or proceed to the nearest emergency department if immediate medical attention and/or treatment is required. Patient Name: _ _ Patient Signature: _ __ _Date: _ Signature: _Date: Xxxxxxx X. Xxxxxxxx, MD If the Patient is a minor, the Patient’s parent or legal guardian must sign below indicating the parent or guardian’s acceptance of the above terms and agreement to pay the Membership Fee on behalf of the Patient: Signature of Parent/Guardian: _Date: Please note_ MEDICARE OPT-OUT AND LIST OF PRACTITIONERS‌ I AGREE, UNDERSTAND AND EXPRESSLY ACKNOWLEDGE THE FOLLOWING: • The Practitioners listed below (the “Practitioners”) have all opted out of the Medicare program effective on dates indicated after their names for a period of at least two years. • Neither Evolve makes every effort nor any Practitioner is involuntarily excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act. • I accept full responsibility for payment of Evolve’s and Practitioners’ charges for all items and services furnished to minimize lab costs me by Evolve. • Medicare fee limitations do not apply to what Evolve and the Practitioners may charge for our members! Covid PCR lab billing is done by the lab processing your sample and it is items or services they provide to me. • I will not within our ability to control this cost. Our member cost for lab processing of PAP smears is also steeply discounted. PAP alone is $30 for our members submit a claim (average national price is $88or request that Evolve or any Practitioner submit a claim) and PAP with HPV is $87 for our members (average national price is $129). Women’s health can be very expensive if paying out-of-pocket. In addition to the fee Medicare program for payment for any items or services provided to me by Evolve or any Practitioner, even if the lab (PAP+HPV=$129)items or services are covered by Medicare Part B. • Neither Evolve nor any Practitioner will submit a Medicare claim for items or services they furnish to me, you can expect to pay $65 to $125 and no Medicare reimbursement will be provided for the visit PLUS $90 to $360 for the Pelvic Examsuch items or services. • CBC Medicare payment will not be made for any items or services provided to me by Evolve or any Practitioner even if those items or services would have otherwise been covered by Medicare if I had not signed this Patient Agreement and this Attachment B, and a proper Medicare claim had been submitted. • I enter into this Patient Agreement with the knowledge that I have the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that I am not compelled to enter into private contracts that apply to other Medicare-covered items and services furnished by other physicians or practitioners who have not opted out of Medicare. • Medigap plans do not provide payment or reimbursement for items and services (such as any Services provided to me by Evolve or the Practitioners) not paid for by Medicare, and other supplemental plans may likewise deny payment or reimbursement for such items and services. • I am not currently in an emergency or urgent health care situation, and do not currently require emergency care or urgent health care services. • A copy of this Patient Agreement with this Attachment B has been provided to me. _ _ _ Date: _ Schedule your payments to be automatically charged to your credit card. Just complete blood count) • CMP (comprehensive metabolic panel) • Lipid analysis • TSH/T4 (thyroid stimulating hormone and thyroid hormone) • PSA (prostate specific antigen) for men onlysign this form to get started!