New Patient Questionnaire

1) Communications. You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.

2) You can request a restriction in our use or disclosure of your health information for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment of your care, such as family members and friends. We are not required to agree to your request; however, if we do not agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

3) You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records but not including psychotherapy notes. You must submit your request in writing to Jason M. Cuellar, M.D., at the address listed above.

4) You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is by or for our practice. To request an amendment, your request must be made in writing and submitted to Jason M. Cuellar, M.D. at the address listed above. You must provide us with a reason that supports your request for amendment.

5) Right to a copy of this notice. You are entitled to a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a copy of this notice, contact our front desk receptionist.

6) Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Jason M. Cuellar, M.D., at the address listed above. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

7) Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.

If you have any questions regarding this notice or our health information privacy policies, please contact Jason M. Cuellar, M.D., using the address or telephone number listed above.

Dear Patient:

To respect your privacy, please tell us which of the following numbers we should call to communicate with you regarding appointment reminders, lab results, etc. Only list the phone number, or numbers you want us to call. Please specify if a message can be left on an answering machine or voice mail with a spouse or significant other or with another designated person.

If yes, please indicate date(s) and procedure(s) below:

ASSIGNMENT OF ALL RIGHTS AND BENEFITS:

In exchange for and in connection with any and all of the medical and related (“services”) provided to me by Jason Cuellar, M.D., LLC. (“Physician”), I hereby assign to Physician all of my rights, benefits, privileges, protections, claims and any other interests of any kind whatsoever, without limitation, that I had, have or may have in the future pursuant to or in connection with any insurance policy or plan, health benefit plan, health management agreement, risk-bearing agreement, trust, fund or any other source of payment, insurance, indemnity or health or medical coverage of any kind (collectively, “Health Coverage”).

This assignment includes, without limitation, direct payment by my insurance carrier or health plan directly to Physician and/or its designated associates for the Services, appeal rights (both internal and external), fiduciary rights, rights to sue, rights to payment, rights to full and fair claims review, rights to penalties or interest, rights to plan documents and plan information, and rights to notices and disclosures from any source (collectively, “Rights”). I am here by transferring to Physician all of these Rights under any Health Coverage to which I am now, previously, or may be entitled to in the future with respect to the Services. Unless otherwise agreed between me and Physician, this assignment is irrevocable.

APPOINTMENT OF AUTHORIZED REPRESENTATIVE:

I hereby designate Physician and/or Physicians’ designated agents and representatives as my duly authorized representative(s) in connection with all matters arising from or relating to Rights and Health Coverage, such that Physician completely and without reservation “stands in my shoes” and takes my place for all applicable purposes, and is granted absolute power and legal authority to seek, claim and directly receive payment or reimbursement for Services; challenge or appeal any adverse benefit determination of any kind whatsoever; or take any other action or obtain anything that I would have been entitled to do, seek, claim, appeal or obtain in my own capacity pursuant to or in connection with the Rights or Health Coverage in any legal, private, administrative, formal or informal process or forum whatsoever and without limitation, including any internal or external appeal, review, grievance or any other process, procedures or entitlement under any Health Coverage.

AGREEMENT TO COOPERATE:

I hereby agree to personally cooperate with, and take all steps necessary, required or reasonably requested by any Health Coverage or by Physician (or its designated associates) to effectuate, perfect, confirm, validate or enforce my Assignment of Rights and Benefits to Physician or authorization of Physician as my authorized representative, as provided above. I promise to make my best efforts to assist and cooperate with Physician as needed or reasonably requested by Physician in connection with any action in any forum, whether legal, formal or informal, without limitation, commenced or maintained by Physician in order to exercise, secure or enforce any Rights provided under the Health Coverage.

PLEASE READ CAREFULLY:

I hereby authorize my insurance carrier to release information regarding medical benefits payable under my policy, and to pay medical benefits directly to Jason M. Cuellar, M.D., Inc or Jason Cuellar MD LLC, a medical corporation.

I hereby authorize any medical care provider to release any medical records and reports concerning my illness and/or treatment directly to Jason M. Cuellar, M.D. a photocopy of this authorization is as valid as the original.

CERTIFICATION OF ACCURATE PERSONAL AND COVERAGE INFORMATION:

I certify that the personal and Health Coverage information that I have provided to Physician (on the “Patient Information Sheet” or otherwise) is, to the best of my knowledge, accurate, complete and correct and that the Health Coverage information is current and in effect as of the date of this form. I certify that I have furnished all required information requested by Physician regarding any and all insurance policies or plans, health benefit plans, health management agreements, risk-bearing agreements, trusts, funds or any other source of payment, insurance, indemnity or health or medical coverage of any kind that may be responsible for my medical costs and expenses. Should my Health Coverage change or experience any additions, deletions or cancellations of coverage or benefits for any reason, I agree that I will notify Physician’s office of such changes immediately. I agree that I will be responsible for any charges resulting from changes to my Health Coverage should they adversely affect the payment of health insurance or plan benefits to Physician.

ACKNOWLEDGEMENT OF PATIENT RESPONSIBILITY FOR ALL CHARGES:

I understand and agree by signing below that I am financially responsible for all charges regarding the medically necessary and related medical services rendered to me by Jason M. Cuellar, M.D., Inc (“Physician”). As a courtesy to me, Physician may submit a claim of Physician’s charges for payment to my health insurance carrier and/or health plan (“Health Coverage”) pursuant to the attached “Assignment of Benefits” agreement that I am executing herewith. I hereby acknowledge that Physician may release my medical records to my health insurance carrier or health plan, or to Physician’s designated Business Associates, as becomes necessary to process, complete or enforce any claim for payment submitted by Physician to my Health Coverage. In the event that my Health Coverage refuses to cover any portion of the charges submitted by Physician for payment, I understand and agree that I (or parties responsible for me) shall be liable for any remaining unpaid charges and, unless Physician and I agree otherwise, I agree to pay such charges no later than sixty (60) days upon receiving an invoice for payment from Physician. Physician reserves the right to require that I pay any deductible required by my Health Coverage or other deposit prior to services.

LATE CHARGES AND ATTORNEY’S FEES:

I agree to pay all charges for which I am liable in a timely manner. I understand and agree that a late charge of 1.5% or $10.00 per month (whichever is greater) will be charged on accounts past due 60 days or more. If my account is referred to Physician’s legal counsel or a collection agency to obtain payment, or if legal action is brought against me, I agree to pay the total amount due with applicable late charges or interest as well as all reasonable attorney’s fees or collection fees or related expenses incurred in collecting or recovering payment on my debt.

CANCELLATION CHARGE:

I understand that a twenty-four (24) hour notice of cancellation of my appointment is required or a $250.00 charge will be owed and added to my account.

COPY VALID AS ORIGINAL: I agree that a photocopy of this signed form is as valid as the original and may be used in place of the original signed form.

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by the Florida Arbitration Code, Chapter 682, and not by a lawsuit or resort to court process except as Florida law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean both the mother and the mother's expected child or children.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rate share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. Arbitration shall take place within 30 days after the completion of discovery as provided in the Florida Rules of Civil Procedure (Rules 1.2801.390) and the decision of the arbitration panel shall be binding upon all parties for all purposes. The time for responding to discovery requests shall be 10 days. All discovery shall be completed within 2 months after the appointment of the panel of arbitrators, unless the time for discovery is extended for good cause by the panel. The arbitration panel shalldecide any disputes regarding discovery. The arbitration panel is expressly authorized to award all reasonable fees and costs, including attorney's fees, to the prevailing party against any party who has violated this Agreement. The parties agree that the arbitrators have the immunity of a judicial office from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.

The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date thereof is received, the claim, if asserted in a civil action, would be barred by the applicable Florida statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the Florida Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:

Effective as of the date of first medical services.

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

Please respond to each question or statement by marking one box per row.

Please respond to each item by marking one box per row.

This questionnaire is designed to help us better understand how your neck pain affects your ability to manage every day life activities. Please mark in each section the one box that applies to you. Although you may consider that two of the statements in any one section relate to you, please mark the box that most closely describes your present day situation.

This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in everyday life. Please answer by checking one box in each section for the statement which best applies to you. We realize you may consider that two or more statements in any one section apply but please just check the box that indicates the statement which most clearly describes your problem.

You are receiving this notice because Dr. Jason M. Cuellar is not in your health plan's network and is an out-of-network provider. By receiving this care from an out-of-network provider, it will cost you more out of pocket as opposed to seeking treatment from an in-network provider.

Out-of-Network Provider: Jason M. Cuéllar, M.D.

Total cost of what you are being asked to pay: $500

By signing, I understand that I am giving up my federal consumer protections and will have to pay more for out-of-network care.

With my signature, I acknowledge that I am consenting of my own free will and I am not being coerced or pressured. I also acknowledge that:

• I am giving up consumer billing protections under federal law.
• I may have to pay the full charges, or a discounted fee at the discretion of the out-of-network provider.
• I was given a written notice that explained that Dr. Jason M. Cuéllar was not in my health plan's network, described the estimate cost of each service, and disclosed what I will owe if I agree to be treated by Dr. Jason M. Cuéllar.
• I received the notice electronically via email.
• I fully and completely understand that some or all of the amounts that I pay will not count towards my health plan's deductible or out-of-pocket maximum.
• I can end this agreement by notifying Dr. Jason M. Cuéllar in writing before receiving services and transferring my care to another surgeon.

IMPORTANT: You do not have to sign this form. If you do not sign the agreement, you will not be treated, and you can choose to get care from a provider who is in your health plan's network.