Common use of Payment Authorization; Execution Clause in Contracts

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx Xxxxxx, MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: X. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands and agrees to send checks for applicable Member Amenities Fees to: Program Member understands that credit card payments will be processed by Signature MD, Inc. as agent for Xxxxxx Xxxxxxxxx, M.D. and agrees to make payments by check payable to “SignatureMDXxxxxx Xxxxxxxxx, M.D., A Medical Corporation”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxxxxxx, MDM.D. A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services personalized care program between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-fourth (1/4) of the Member Amenities Personalized Care Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx Xxxxxxx X. xxXxxxxx-Xxxxxx, Secretary /Treasurer Additional Program Members (Xxxxxxx X. xxXxxxxx-Xxxxxx, MD) A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Concierge Medicine Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except if the Authorization is specifically related to the individual’s enrollment or eligibility, or for specific exceptions not applicable herethe Entity’s underwriting or risk rating determinations. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date 3. Print Patient’s Name Signature of Patient or Patient’s Representative Date 4. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx XxxxxxXxxxx Xxxxx, MDDO A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: X. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx Xxxxxxxx Xxxxxx, MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: X. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx XxxxxxXxxxxxxx Xxx, MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: X. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxxxxx Xxxxx-Xxxxx, MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date 3. Print Patient’s Name Signature of Patient or Patient’s Representative Date 4. Print Patient’s Name

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-­‐fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx XxxxxxXxxxxxxx Xxx, MD, Member A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-­‐CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION: 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX AME X CARDHOLDER NAME Program Member understands and agrees to send checks for applicable Member Amenities Fees to: Program Member understands that credit card payments will be processed by Signature MD, Inc. as agent for Xxxxxx Xxxxxxxxx, M.D. and agrees to make payments by check payable to “SignatureMDXxxxxx Xxxxxxxxx, M.D., A Medical Corporation”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxxxxxx, MDM.D. A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services personalized care program between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxxxxx Xxxxx-Xxxxx, MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date 3. Print Patient’s Name Signature of Patient or Patient’s Representative Date 4. Print Patient’s Name

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-­‐fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. CarolinaMD and agrees to make payments by check payable to “SignatureMDCarolinaMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx XxxxxxXxxxx Comfort Le, MDPresident A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-­‐CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative DateAGREED

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx oneVfourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx XxxxxxX. Xxxxxxxx, MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. EJMAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. EJMAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. EJMAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIPJCODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION: 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxxxx X. Xxxxx, MDM.D. A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date 3. Print Patient’s Name Signature of Patient or Patient’s Representative Date 4. Print Patient’s Name

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-­‐fourth (1/4) of the Member Amenities Personalized Care Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx Xxxxx X. Xxxxxx, MDPresident A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-­‐CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Concierge Medicine Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except if the Authorization is specifically related to the individual’s enrollment or eligibility, or for specific exceptions not applicable herethe Entity’s underwriting or risk rating determinations. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date 3. Print Patient’s Name Signature of Patient or Patient’s Representative Date 4. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx oneVfourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx XxxxxxXxxx Xxxxxxxxx, MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. EJMAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. EJMAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. EJMAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-­‐fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx Xxxxx X. Xxxxxx, MDPresident and Treasurer Additional Program Members (POTOMAC INTERNISTS, P.C., Xxxxxx) A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: X. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-­‐CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date 3. Print Patient’s Name Signature of Patient or Patient’s Representative Date 4. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-­‐fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx XxxxxxXxxxx X. Xxxxxxx, MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-­‐CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date 3. Print Patient’s Name Signature of Patient or Patient’s Representative Date 4. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities FeeMembership Fees, or (ii) hereby authorizes Personalized Care Concierge Practice’s designee to xxxx xxxXxxxxxx one-­‐fourth (1/4) of the Member Amenities Membership Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx XxxxxxXxxxx, MDPresident A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-­‐CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative DateAGREED

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx XxxxxxXxxxxxx Xxxxxxx, MDSole Member A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: X. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx oneVfourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx XxxxxxXxxxxxxx X. Xxxxx, MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. EJMAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. EJMAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. EJMAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date 3. Print Patient’s Name Signature of Patient or Patient’s Representative Date 4. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx Xxxxxx, MD. A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: X. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx bill one-fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME NUMBER EXPIRATION CC ZIP CODE Program Member understands that credit card payments will be processed by Signature MDKENTUCKYONE HEALTH MEDICAL GROUP, Inc. and agrees to make payments by check payable to “SignatureMD”INC. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx Xxxxxx, MDSCHEDULE 1 TO PERSONALIZED CARE MEMBERSHIP AGREEMENT A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: X. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services personalized care program between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-­‐fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx Xxxxxxx Xxxxxx, MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-­‐CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx Xxxxxx, MD. A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: X. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-­‐fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. CarolinaMD and agrees to make payments by check payable to “SignatureMDCarolinaMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx XxxxxxXxxxx Comfort Le, MDPresident A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-­‐CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative DateAGREED

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities FeeMembership Fees, or (ii) hereby authorizes Personalized Care PracticePhysician’s designee to xxxx xxxXxxxxxx one-­‐fourth (1/4) of the Member Amenities Membership Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) ByDate: Xxxxxx Xxxxxx, MDDate: A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-­‐CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Concierge Medicine Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entityindividual name in Section 2 above. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except if the Authorization is specifically related to the individual’s enrollment or eligibility, or for specific exceptions not applicable herethe Entity’s underwriting or risk rating determinations. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-­‐fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx XxxxxxX. Xxxxx, MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-­‐CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION: 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date 3. Print Patient’s Name Signature of Patient or Patient’s Representative Date 4. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Signature) (Print Name) By: Xxxxxx XxxxxxXxxxxxx X. Xxxxx, MDM.D. A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date 3. Print Patient’s Name Signature of Patient or Patient’s Representative Date 4. Print Patient’s Name

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx XxxxxxXxxxxxxxx XxXxxxx, MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: X. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx oneVfourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Signature) (Print Name) By: Xxxxxx XxxxxxXXXXXX X. XXXXX, MDMember A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. EJMAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. EJMAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. EJMAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities FeeMembership Fees, or (ii) hereby authorizes Personalized Care PracticePhysician’s designee to xxxx xxxXxxxxxx one-half (1/41/2) of the Member Amenities Membership Fee (that is, $ ) per calendar quarter semi-annual (3 6 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx Xxxxxx, MDM.D. A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. EJMAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. EJMAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative DateC. EJMAIL ADDRESS

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx bill one/fourth (1/4) of the Member Amenities Fee (that is, $ $375.00) per calendar quarter (quarter, 3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD ! Visa ! MC ! Discover ! AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD” 0000 Xxxxxxxxx Xxx, Xxxxx 000, Xxxxxx xxx Xxx, XX 00000 Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. Program Member Riverview Personalized Care ,LLC (Print Name) By: Xxxxxx Xxxxxxxx X. Xxxxxx, MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. ACKNOWLEDGED AND AGREED INITIALS: X. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative DateC. E-MAIL ADDRESS

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-­‐fourth (1/4) of the Member Amenities Personalized Care Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx XxxxxxYzhar Charuzi, MDM.D., FACC A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-­‐CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-­‐MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-­‐CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Concierge Medicine Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except if the Authorization is specifically related to the individual’s enrollment or eligibility, or for specific exceptions not applicable herethe Entity’s underwriting or risk rating determinations. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx Xxxxx Xxxxxx, MD A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: X. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities FeeMembership Fees, or (ii) hereby authorizes Personalized Enhanced Cardiac Care Practice’s designee to xxxx xxxXxxxxxx one-fourth (1/4) of the Member Amenities Membership Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) ByDate: Xxxxxx Xxxxxx, MDDate: A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Enhanced Cardiac Care Medicine Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge Enhanced Cardiac Care medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entityindividual name in Section 2 above. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except if the Authorization is specifically related to the individual’s enrollment or eligibility, or for specific exceptions not applicable herethe Entity’s underwriting or risk rating determinations. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx Xxxxxx, MD. A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: X. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date

Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to xxxx xxxXxxxxxx one-fourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. * Member Amenities Fees will automatically increase three percent (3%) on each annual anniversary of the Effective Date. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: Xxxxxx Xxxxxx, MD. A. 2ND MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: X. A. 3RD MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODEZIP-CODE X. F. ACKNOWLEDGED AND AGREED INITIALS: A. 4TH MEMBER’S NAME B. DATE OF BIRTH X. XXXXXX C. E-MAIL ADDRESS D1. HOME PHONE D2. MOBILE PHONE D3. OFFICE PHONE D4. FAX E1. MAILING ADDRESS E2. CITY E3. STATE E4. ZIPJCODE X. ZIP-CODE F. ACKNOWLEDGED AND AGREED INITIALS: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION 1. This Authorization concerns the following medical information about me: demographic information including but not limited to age, address, phone number, email address, name of insurer. 2. This information may be used or disclosed by the Entity to SignatureMD, Entity’s Business Associate (as defined under HIPAA). 3. This authorization automatically expires after the termination, for any reason, of my Personalized Care Membership Agreement with the Entity. 4. The purpose(s) of this use or disclosure is: At my individual request, in order to facilitate and help administer concierge medical services between me and the Entity. 5. I understand that at any time I have the right to revoke this Authorization pursuant to the Entity’s Notice of Privacy Practices, except to the extent that the Entity has already acted in reliance on the Authorization. I understand that I may revoke this Authorization by contacting the Entity. 6. I understand that once information leaves the Entity, the Entity no longer directly controls the information. 7. I understand that the Entity is prohibited from requiring that I sign this Authorization as a condition of my enrollment or eligibility for benefits, except for specific exceptions not applicable here. 1. Print Patient’s Name Signature of Patient or Patient’s Representative Date 2. Print Patient’s Name Signature of Patient or Patient’s Representative Date