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 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 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 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: _ 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 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 me by Evolve. • Medicare fee limitations do not apply to what Evolve and the Practitioners may charge for the items or services they provide to me. • I will not submit a claim (or request that Evolve or any Practitioner submit a claim) to the Medicare program for payment for any items or services provided to me by Evolve or any Practitioner, even if the 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, and no Medicare reimbursement will be provided for such items or services. • 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 and sign 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 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 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 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: _ 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 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 me by Evolve. • Medicare fee limitations do not apply to what Evolve and the Practitioners may charge for the items or services they provide to me. • I will not submit a claim (or request that Evolve or any Practitioner submit a claim) to the Medicare program for payment for any items or services provided to me by Evolve or any Practitioner, even if the 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, and no Medicare reimbursement will be provided for such items or services. • 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 and sign 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 IHNC and that I have a right to know my treatment options and actively participate in my 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 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 is 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. 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: _ MEDICARE OPTFECAL OCCULT BLOOD, STOOL GLUCOSE, FINGERSTICK, BLOOD HBA1C (HEMOGLOBIN A1C), 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-OUT AND LIST OF PRACTITIONERS‌ I AGREE, UNDERSTAND AND EXPRESSLY ACKNOWLEDGE THE FOLLOWING: Rays • The Practitioners listed below (the “Practitioners”) have all opted Labs sent out of the Medicare program effective on dates indicated after their names for a period office: clinic staff will notify estimated cost of at least two years. external xxx xxxxxxxx • Neither Evolve 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 me by Evolve. • Medicare fee limitations do not apply to what Evolve and the Practitioners may charge for the items or services they provide to me. • I will not submit a claim (or request that Evolve or any Practitioner submit a claim) to the Medicare program for payment for any items or services provided to me by Evolve or any Practitioner, even if the 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, and no Medicare reimbursement will be provided for such items or services. • 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 Any specialty 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 and sign this form to get started!visit