By signing below, you acknowledge your recognition and understanding of the inherent risks of communicating your health information via unencrypted email and hereby consent to receive such communications despite those risks. Messages containing clinically relevant information may be incorporated into the medical record at the provider’s discretion. By signing below, you also acknowledge that you have the choice to receive communications via other more secure means such as by telephone. By signing below, you agree to hold Christopher M. Shaari, M.D., P.C. harmless for unauthorized use, disclosure, or access of your protected health information sent to the email address you provide.

All professional services rendered are charged to the patient. Necessary forms will be completed to expedite insurance carrier payments. The patient is responsible for all fees, deductibles and copayments regardless of insurance coverage unless forbidden by prior insurance contracts. You are expected to pay for services at time they are rendered unless other arrangements have been made in advance. I authorize Christopher M. Shaari, M.D., P.C., to appeal to my insurance company on my behalf. I hereby authorize Christopher M. Shaari, M.D., P.C. to furnish to insurance companies, their representatives or designated attorney and requesting physicians, any information· concerning my illness and treatments. I hereby assign to Christopher M. Shaari, M.D., P.C. all payments for medical services rendered to myself or my dependents. I acknowledge the possibility that a check and or checks may be sent directly to me instead of you, my provider. I understand this money is not mine even though the check may be written to me. I understand you are billing my insurance company as a courtesy to me but the money paid by the insurance company belongs entirely to you. I, therefore, agree to immediately, but certainly no later than 5 days upon receipt of any such monies, endorse this check and forward this money directly to Christopher M. Shaari, M.D., P.C.. I will make no attempt to negotiate what portion I send to you. I hereby further assign to Christopher M. Shaari, M.D., P.C. all of my rights under my insurance contract, including all of my rights governed by the statues and regulations of the Employee Retirement Income Security Act (ERISA), including, without any limitation whatsoever, my rights to "recover benefits" under ERISA Section 502(a)(1)(B), my rights to recover civil statutory penalties under ERISA Section 502(c)(1)(B); and my rights to pursue breach of fiduciary claims under ERISA Sections 502(a)(2) and 502(a)(3). I understand that I am responsible for co-payment, deductible or for any amount not covered by my insurance. If any collection proceedings are required to cover any outstanding balance, I understand I will be responsible for said costs including attorney fees of 33.33% of the unpaid balance. These costs are above and beyond any balance for services rendered.

We are committed to providing you with the best possible care and are pleased to discuss our professional fees with you at any time.Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy or your financial responsibility. PATIENTS MUST FILL OUT PATIENT INFORMATION FORMS PRIOR TO SEEING THE DOCTOR. WE WILL REQUEST TO PHOTOCOPY YOUR INSURANCE CARD(S) FOR YOUR FILE. • REFERRALS – If your plan requires a referral from your primary care physician, it is YOUR responsibility to obtain it prior to your appointment and have it with you at the time of your visit. If you do not have your referral, YOU WILL BE REQUESTED TO SIGN A FINANCIAL WAIVER. It is then your responsibility to provide us with the referral within 48 hours or you will be personally responsible for that day’s services. • CO-PAYMENTS – By law we MUST collect your carrier designated co-pay. This payment is expected at the time of service. Please be prepared topay the co-pay at each visit. • OUT OF NETWORK PLANS – You will be responsible for any balance your plan indicates as patient responsibility on their explanation of benefits form. When the provider you are scheduled to see does not participate with your insurance, your plan may not cover out-of-network services, leaving you to pay the full cost. If your plan does cover out-of-network services, you may be assessed a higher co-pay, deductible and co-insurance for out of-network care. You will be responsible to pay these higher amounts plus any difference between the allowed amount and the amount the out-of network provider charges for the service. Private Insurance Authorization for Assignment of Benefits/Information Release: I, the undersigned, authorize payment of medical benefits to Christopher M. Shaari, M.D., P.C. for any services furnished. I understand that I am financially responsible for any amount not covered by my contract. I also authorize any holder of medical information about me to release to my insurance company (or their agent) information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits. • SELF-PAY PATIENTS – Payment is expected at the time of service unless other financial arrangements have been made prior to your visit. • MEDICARE – We will submit claims to Medicare. The patient will be responsible for the deductible and the 20% co-insurance, which can be billed to a secondary insurance if you have one. Medicare Lifetime Signature on File: I request that payment of authorized Medicare benefits be made on my behalf to Christopher M. Shaari, M.D., P.C. for any services furnished to me. I authorize any holder of medical information about me to release to the CMS (and its agents) any information to determine these benefits payable for related services. This information will be used for the purpose of evaluating and administering claims of benefits. • DIVORCED/SEPARATED PARENTS OF MINOR PATIENTS – The parent who consents to the treatment of a minor child is responsible for payment of services rendered. Christopher M. Shaari, M.D., P.C. will not be involved with separation or divorce disputes. You are responsible for the timely payment of your account. Should it become necessary for us to use an outside agency to collect payment from you, you will be additionally responsible for whatever charges we incur as a result of this. WE ACCEPT CASH, CHECKS, MASTERCARD, VISA, OR DISCOVER CARD. THANK YOU for taking the time to review our policies. Please feel free to ask any questions or share special concerns with us. I hereby agree that you may contact me for whatever reason concerning my account on any and all of the phone numbers I have provided to you, including but not limited to home phone, work phone, cell phone, email or any other form of contact.