I, the undersigned, hereby consent to medical care and treatment provided through this provider organization, as ordered by my health care provider. This includes my consent for all medical services provided under the general and other health care providers or designees under the direction of a physician as deemed reasonable and necessary.

I am aware that the practice of medicine in not an exact science and I acknowledge that no guarantees have been made to me as a result of treatments or examinations that I received or will receive.I understand that I have the right to discuss my treatment plan with my physician and to discuss the purpose, and potential risks and benefits of any tests or procedures that are ordered by my physician.

I understand that students in the medical field under appropriate supervision may observe or assist in the delivery my medical care and that I have the right to refuse such services provided by students at any time.

I understand that if I need to review or obtain a copy of my medical records, I must complete the access request form available at this location. This form will allow me or a person that I authorize to obtain copies of my medical records.

I request that payment of authorized medical benefits is made on my behalf directly to this provider organization for medical care and treatment(s) furnished to me.

I authorize this provider organization to release any medical information to my health insurance carrier and/or other third party payors that is necessary to collect payments, process related health insurance claims and/or to verify plan benefits in accordance with the Health Insurance Portability and Accountability Act ("HIPAA") standards and applicable state privacy laws.

I authorize payment of service(s) otherwise payable to me under the terms of my private, group, employer's plan or group health insurance plan directly to this provider organization.

I hereby authorize that photocopies of this form to be valid as the original. If the medical benefits are not assignable to this provider organization or if I receive payments from my insurance provider or any other third party payor for services rendered on my behalf by this provider organization,I will forward such payments to this provider organization immediately upon receipt.

I understand that telemedicine or telehealth involves the use of secure interactive videoconferencing under the that enable a physician licensed by the state where my clinic is located, or a health care professional equipment and care delegation and supervision of a physician licensed by the state where my clinic is located, to deliver acting heath assessment, medical diagnosis, consultation, treatment, and monitoring of a patient at a separate location and the transfer services to patients when located at different sites. Such health care services may include, without limitation, of data, each as permitted by applicable law. All electronic transmission of data will be restricted to authorized recipients in compliance with the HIPAA and applicable state privacy laws.

I understand that there are risks and benefits of using telemedicine or telehealth services. Some of the benefits include easier access to medical care and avoiding the need to travel to the health care provider. Some of the risks of associated with the use of telemedicine or telehealth services include, without limitation, loss of records from failure of electronic equipment, power failure with loss of communication and invasion of electronic records from outsiders (hackers). In addition, signs and symptoms that may be detected during an in-person physical examination may not detected through telemedicine.

I understand that I have the option of seeing the health care provider face to face instead of participating in telemedicine or telehealth. I acknowledge the risks and benefits of using telemedicine and telehealth services. services and hereby consent to use of telemedicine and/or telehealth to perform medical treatment and I understand that I have the right to refuse to participate in a telemedicine visit or telehealth services and that my refusal will be documented in my medical records. I also understand that my refusal will not affect my right to future medical care or treatment by the provider organization.

I understand that certain in-home technology that I may select for use in my home, for example Amazon's Alexa and certain "smart" televisions, may have the capacity to "listen in" to activity in my home, including interactions during in- home health care visits. I understand and agree that I am solely responsible for configuring such equipment to ensure the privacy of communications with health care providers during any in-home visits or telemedicine appointments.

I agree to pay for services that are not covered or covered charges not paid in full including, but not limited other any co-payment, third co-insurance and/or deductible, or charges that are not covered by my insurance provider to, from party payor.

I agree to be responsible for all reasonable attorneys' fees and collection costs resulting or my failure to pay any fees or amounts for which I am financially responsible.

I agree that in order for this provider organization and its collection agents to service my account or to collect I may owe, the provider organization and its collection agents may contact me by telephone at any telephone and/or number, including my cellular telephone number, that I have provided to the provider organization any at any telephone number that its collection agents have obtained or, at any telephone number forwarded or transferred from any such telephone number, regarding the services rendered, or my related financial obligations. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable. If applicable, data charges and rates from my cellular carrier may apply.

I understand that my protected health information may be used and disclosed without my authorization to allow treatment, payment, and health care operations as described in the Notice of Privacy Practices.

I understand that the of Privacy Practices may be updated periodically and that a copy of the updated Notice of Privacy Practices will be provided to me upon request.

I understand that, unless I have requested restrictions in writing, the type of information that this provider organization may release to third parties may include certain sensitive medical records including, but not limited to, records regarding psychological treatment, Acquired Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV) infections, developmental disabilities, alcoholism, or drug dependence during any period of care and treatment. A form to request restriction of this type of information is available at this location.

I understand that it may be necessary for this provider organization and its health care providers to obtain information regarding prescribed medications that I am currently taking or have taken in the past for medical care and treatment purposes.

I hereby authorize this provider organization and the health care providers to obtain and review my external prescription history from my current and former medical care providers, pharmacies, and drug monitoring agency.

I understand that I will not be denied medical care or treatment if I refuse to authorize this provider organization and its health care providers to access to my external prescription history, except where access or prescription drug history queries are required by applicable law.

By signing below, I acknowledge that I have received a copy of of Privacy Practices that is effective, 2019. -HIPPA Notice

If this form is signed by someone who is not the patient listed above (e.g. a parent/guardian/legal representative), please provide the signor's name and his or her authority to act for the patient.

I hereby give my permission to this provider organization to release or to request personal health information contained in my medical records to the organization listed.

I understand that this authorization will allow this provider organization and its affiliates to use or disclose my protected health information. I understand that my medical record may contain sensitive information such as mental health, HIV, AIDS, substance use disorders, sexual abuse and /or other related conditions. I understand that these records are classified as privileged and confidential and cannot be released to me or those designated by me or my legal guardian without an express and informed written consent. In addition, I understand that these records will not be released to entities other than those designated by myself or my personal representative as provided by state or federal law.

I hereby authorize Royalty Specialty Care and its affiliates, its employees and agents, to use and disclose protected health information (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me and which identifies my name, address, social security number, Member ID number) for the purpose of helping me to resolve claims and health benefit coverage issues.

I understand that any personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws.

I understand that I have a right to revoke this authorization by providing written notice to. However, this authorization may not be revoked if, it's employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services. I have been advised of this practice's Privacy Practices, Release of Billing Information policy, Assignment of Benefits policy, and grant the practice Medication History Authority.

If applicable, Legal Representatives sign below:

By signing this form, I represent that I am the legal representative of the Member identified above and will provide written proof (e.g., Power of Attorney, living will, guardianship papers, etc that I am legally authorized to act on the Member's behalf with respect to this authorization form.