CRISSP New Patient Consent Form

The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility. If you do not agree, you must contact CRISSP to ask for alternate methods. A copy of your signed consent agreement is available via the patient portal.

I authorize my physicians at Center for Regenerative and Interventional Spine and Sports Pain (hereafter referred to as CRISSP), their associates, assistants, its house staff, employees, and students to provide the medical care, tests, procedures, drugs, blood or blood products, services and supplies considered advisable by my physician(s). These services may include pathology, radiology, emergency services, telehealth/telemedicine, dispensing and administration of medications and/or durable medical equipment, and other special services ordered by my physician(s). In consenting to treatment, I have not relied on any statements as to results. I authorize that students and scribes or other remote staff may be listening into and/or participating in my healthcare. I further authorize my physician or staff to examine, use, store and/or dispose of in any manner (except for organ donation and/or transplantation) any bones, organs, tissues, fluids or parts removed from my body. In the event that any personnel assisting in the provision of care and treatment suffer inadvertent exposure to any of my blood and/or other bodily substances that is capable of transmitting disease and I am unable to timely consult with my physician prior to testing, I consent to limited testing to determine the presence, if any, of antibodies to or infectious agents of Hepatitis A, B, and C and HIV. I also consent to screening for behavior health conditions and Behavioral Health Integration (BHI) services through the clinic and any applicable copays. I also consent to Chronic Care Management (CCM) services and the clinic's CCM program and any applicable copays. I also consent to remote physiologic monitoring (RPM) and the clinic's RPM program and any applicable copays. All copies of consent forms can be obtained from the clinic or by going to the website to view all CRISSP policies.

I consent to the electronic storage and transmission of patient health information. I understand that I will have access to my chart and a means of communication with the clinical team through the patient portal, the link which is available on the clinic website crissp.net. I hereby authorize CRISSP and its affiliates, my treating physicians to release by electronic means or otherwise any medical and/or billing information concerning my care, including copies of my medical records, to the following: i. the health professionals involved or who will be involved in my care either at CRISSP or in the course of any of my treatments by providers with CRISSP, including following hospitalization or surgery; ii. the person or entity responsible or who may be responsible to pay for any or all of my care rendered by CRISSP or on behalf of CRISSP or any entity that contracts with CRISSP to obtain payments for services rendered; iii. any governmental or other entity as required by law for purposes of reporting, or for purposes of determining eligibility in government sponsored benefit programs; iv. CRISSP personnel who perform activities that assess or evaluate the health or other services that the clinic or other health professionals may provide, including but not limited to, case management, accreditation surveys, or clinical reviews; v. the supplier of any blood or blood products which may be administered to me for the purposes of quality control and recipient monitoring; or vi. any continuing care, residential, or long-term care facility, or home health agency for the purpose of providing services for my care. vii. for medical research and/or research publications, with the understanding that any public-facing data will be de- identified prior to publication.

I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize the release of medical or other information to the Medicare Program or its intermediaries or carriers concerning this or a related claim filed by CRISSP. I request that payment of authorized benefits be made on my behalf. I understand that I am responsible for the Part A and Part B deductible for each year and/or visit, the remaining co- insurance and any other non-covered personal charges. I hereby acknowledge receipt of the Medicare/Tricare letter entitled “An Important Message from Medicare/Tricare.” I (or my representative) certifies that I or he/she has read (or if the patient/representative is unable to read has had the form read to him/her) and understand(s) and accept(s) the above and further certifies that I am the patient or am duly authorized on behalf of the patient to execute such an agreement.

I consent to and authorize the storage and taking pictures, video and/or electronic images in the course of my visit/procedure/operation for the purpose of medical education/training or medical research or to facilitate my clinical care; provided, however, that my identity may not be revealed by any published pictures or descriptive text accompanying any photographs or images.

CRISSP provides facilities that may be used for the safekeeping of money, valuables or other personal effects, including but not limited to dentures, eyeglasses or contact lenses, if I choose not to use those facilities, I understand that I assume all responsibility for the loss or damage of any money, valuables or other personal effects during my visit.

In accordance with the above terms and in consideration of the services provided to the below-signed patient by CRISSP the undersigned agrees, whether he/she signs as patient or guarantor, to pay CRISSP and physicians for all services ordered by the attending physician, or requested by the patient and the patient's family. If the requirements for referral, second opinion or pre-certification of care, as outlined by my insurer, benefit plan or other payor, have not been followed, the patient and/or guarantor may in some instances be personally responsible for all charges incurred, and patient agrees to pay these responsibilities. Patient hereby consents and agrees to not hold CRISSP or it’s physicians, associates, or staff financially responsible for any referral to or treatment by an out-of-network provider, and patient agrees to pay for any such services rendered to patient.

Thank you for choosing the Center for Regenerative and Interventional Spine and Sports Pain for your medical care. We are honored by your choice and are committed to providing you with the highest quality healthcare.

1. The patient is required to provide us with the most correct and updated information about their insurance, and will be responsible for any charges incurred if the information provided is not correct or updated. 2. Please bring a valid photo ID and insurance cards to every visit 3. We strongly encourage all patients to contact the insurance company directly with specific questions regarding coverage. Ultimately, it is the patient's responsibility to know his/ her insurance benefits plan. In addition, the office must be notified prior to the date of service of any changes in insurance. 4. We participate with most major health insurance plans, and will assist you by submitting claims for services rendered. Your insurance carrier may need you to supply certain information directly. It is your responsibility to comply with this request. 5. If you have an insurance plan that requires a referral, it is your responsibility to contact your Primary Care Physician PRIOR to the appointment. Regretfully, many insurers will not cover specialty services without a referral and you will be held responsible for the costs. If we do not have a referral on file and it is required, we will not be able to render services. Patient Payments: 6. Patients are responsible for the payment of copays, coinsurance, deductibles, and all other procedures or treatment not covered by their insurance plan. Payment is due at the time of service. If the patient does not have the co-payment, we are not required to see the patient. Failure to collect or waiver of copayment may constitute fraud under state and federal law. 7. With the exception of self-pay patients, Check, Cashiers Check, or credit card only can be accepted for payment per state regulations. Returned Checks will be charged a $45.00 fee. 8. Any patient balance delinquent after 90 days may be referred to a collection agency. Patients will be responsible for any and all costs associated with the collection agency up to and including legal costs. Any patient balance delinquent after 120 days may be discharged from the practice. If this occurs, the patient will have 30 days to seek alternative medical care. During the 30 day period, the physician will only be able to treat you on an emergency basis. After this 30 day period, the patient will be discharged from the practice.

In accordance with all the above terms and in consideration of all medical services, care, drugs, supplies, equipment, durable medical equipment (DME) and facilities furnished by CRISSP and all physicians, associates, or staff, I authorize direct payment to Kunj Govind Patel MD LLC, a series LLC DBA Center for Regenerative and Interventional Spine and Sports Pain (CRISSP) for all services rendered by the CRISSP physicians, associates, or staff, or requested by the patient and/or patient’s family. This shall include all insurance benefits applicable to this visit and future visits, which are now or which shall become due and payable to Kunj Govind Patel MD LLC, a series LLC DBA Center for Regenerative and Interventional Spine and Sports Pain (CRISSP). In addition, I hereby authorize direct payment to the Kunj Govind Patel MD LLC, a series LLC DBA Center for Regenerative and Interventional Spine and Sports Pain (CRISSP) of all insurance benefits applicable to medical and/or surgical services rendered by physicians for whom Kunj Govind Patel MD LLC, a series LLC DBA Center for Regenerative and Interventional Spine and Sports Pain (CRISSP) is authorized to charge and bill.

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

As a patient in our Practice, it will be your responsibility to keep scheduled appointments. Our office requires notification of cancellation at least 24 hours prior to the appointment or earlier if possible. Your appointment will be cancelled if you are more than 15 minutes late from your scheduled appointment. Please contact our office to cancel and reschedule an appointment. A No Show charge of $25.00 will be applied to your account if advance notice is not given.

I authorize my medical provider(s) listed below to release my records to Center for Regenerative and Interventional Spine and Sports Pain, Dr. Kunj Patel, MD and Associates. Fax: 301-579-4284 Phone: 314-282-7246. Note: If this release pertains to alcohol, drugs, or mental health information, please note that this information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of this information unless additional further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. I understand that a reasonable fee may be charged for duplication of records. An estimate of those charges will be provided upon request prior to duplication.