Specialists Coordination. CLINIC and Physician shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the CLINIC Physician. Annual fees as set out below shall apply to the following Patient(s), who by signing below agree to the terms and conditions of the ACCESS FAMILY MEDICINE Medical Agreement Form. Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Preferred email Spouse Name Date of Birth (MM/DD/YYYY) Age Home Phone Work Phone Cell Phone Preferred email Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age □ Monthly □ Quarterly □ Semi-Annually □ Annually □ Employer I certify that I have read, understand, and agree to the terms set forth in the ACCESS FAMILY MEDICINE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: 0-19 years of age $10 per month* 0-19 years of age $50 per month** 20-44 years of age $50 per month 45-64 years of age $75 per month 65+ years of age $100 per month Re-Enrollment Fee $200 per household*** *With the enrollment of at least one adult member. **Without a fully enrolled adult member. ***Non-refundable fee. Should your membership lapse or be terminated, the re-enrollment fee must be paid again for membership to become active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ This agreement (Agreement) is entered into by and between Access Enterprise, a Nebraska Limited Liability Company, d/b/a Access Family Medicine, Dr. Xxxx Xxxxxxx (Physician), whose principal address is 0000 X Xxxxxx, Xxxxx 000, Xxxxxxx, Xxxxxxxx 00000, and , , NE . The Physician has informed Patient that Physician has opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.

Specialists Coordination. Practice and dentist shall coordinate with medical specialists to whom the patient is referred to assist Patient in obtaining specialty care. Patients understand that fees paid under this Agreement do not include and do not cover specialist fees or fees due to any medical professional other than Xxxxxxxx Dental, LLC staff.

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Specialists Coordination. The physician shall coordinate care with medical specialists and other practitioners to whom the Patient needs referral. The Patient understands that fees paid under this Agreement do not include specialist's fees or fees due to any medical professional other than the Practice staff. CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING PATIENT(S), WHO BY SIGNING BELOW ( OR AS LEGAL REPRESENTATIVE), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Print Patient Name Date of Birth Street Address City, State, Zip Cell Phone Alternate Number Email I Agree to Text Communication: (circle one below) ● Yes ● No Printed Name: Relationship to Patient: Patient Name Date of Birth Cell Phone Alternate Number Email I agree to Text Communication: (circle one below) ● YES ● NO Printed Name: Relationship to Patient: Patient Name Date of Birth Cell Phone Alternate Number Email Agree to Text Communication: (circle one below) ● YES ● NO Printed Name: Relationship to Patient: Patient Name Date of Birth Cell Phone Alternate Number Email I agree to Text Communication: (circle one below) ● YES ● NO Printed Name: Relationship to Patient:

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Specialists Coordination. The physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals to outside specialty care. The Patient understands that fees paid under this Agreement do not include or cover specialist's fees or charges from any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patient. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Print Patient Name Date of Birth Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes �� No Signature: Patient Name Date of Birth Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 YES 🞎 NO Signature Total Monthly Membership Fee $ Enrollment Fee $150 per Member* (one time, non-refundable) $ Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ Name on Account: Bank Name: Account #: Routing #: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amount:

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Specialists Coordination. Practice and dentist shall coordinate with medical specialists to whom patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist fees or fees due to any medical professional other than Odon Family Dentistry staﬀ.

Specialists Coordination. Physician shall coordinate with Patient’s medical specialists to assure continuity of care, and if necessary, shall assist in obtaining a referral for specialty care. Patient understands that monthly fees paid under this Agreement do not include specialist’s fees or fees due to any outside medical professional. These are the patient’s responsibility but Patient may submit such charges to insurance. The fees as set out in the attached Appendix C, shall apply to the following Patient(s), who by signing below, (or) as Parent or Legal Guardian certify that they have read and agree to the terms and conditions of this Agreement: Patient Name Date of Birth Email Do you agree to text message communication? YES NO Signature of Patient / Guardian: Date: One Time Consultation $349.00 After Hours Visit (If Applicable) $ 50.00

Specialists Coordination. PRACTICE and Physician shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understandsthatfeespaidunder this Agreementdonotinclude anddo notcoverspecialist’sfees or feesduetoanymedical professionalotherthanthe PRACTICE Physician. Monthly fees, as set out in Appendix C, shall apply to the following Patient(s): Printed Name DateofBirth(MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Preferred email Spouse Name DateofBirth(MM/DD/YYYY) Age Home Phone Work Phone Cell Phone Preferred email Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age □ Monthly (Credit/Debit Card/Bank Draft) □ Annually (Credit/Debit Card/Bank Draft/Check) 6-24 years of age with a parent enrolled $39 per month* 18-24 years of age without a parent enrolled $49 per month 25-49 years of age $89 per month 50+ years of age $109permonth Enrollment Fee $99** *Patients under 18 require the enrollment of at least one adult member. **Non-refundable fee. Should your membershiplapse or be terminated, the enrollmentfee must be paid again for membership to become active.

Specialists Coordination. The physician shall coordinate care with medical specialists and other practitioners to whom the Patient needs referral. The Patient understands that fees paid under this Agreement do not include specialist's fees or fees due to any medical professional other than the Practice staff. Phone: 000-000-0000 Fax: 000-000-0000 xxx.xxxxxxxxxxxxxxxxxxxxxx.xxx THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING PATIENT(S), WHO BY SIGNING BELOW (OR AS LEGAL REPRESENTATIVE), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Print Patient Name Date of Birth Street Address City, State, Zip Cell Phone Alternate Number Email Printed Name: _ Relationship to Patient: Patient Name Date of Birth Street Address City, State, Zip Cell Phone Alternate Number Email Printed Name: Relationship to Patient: Patient Name Date of Birth Street Address City, State, Zip Cell Phone Alternate Number Email Printed Name: Relationship to Patient: 0000 Xxxxxxx Xx. Phone: 000-000-0000 Fax: 000-000-0000 xxx.xxxxxxxxxxxxxxxxxxxxxx.xxx

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