I hereby authorize Patel Spine Care Medical, Inc. (hereafter referred to as "DOCTOR") to furnish you, my attorney, with an itemized billing statement, copies of my records and a full report of treatment, etc., of myself in regard to the accident in which I was involved.

I hereby authorize and direct you, my attorney, to pay directly to said DOCTOR such sums as may be due and owing it for medical service rendered me both by reason of this accident and by reason of any other bills that are owed by me to the DOCTOR and to withhold such sums received from any settlement, judgment or verdict as may be paid to you, my attorney, or myself. I hereby further grant a lien on my case to said DOCTOR against any and all proceeds received by way of any settlement, judgment, verdict or other recovery to which I may be entitled and which may be paid to you, my attorney, or myself, in connection with the accident in which I was recently involved in order to secure payment to said DOCTOR for the services provided to me by said DOCTOR. I accept and understand that payment is not contingent on any settlement, judgment or verdict and if there is no recovery, the balance owed to DOCTOR shall become due and immediately payable in full and so I promise to pay according to these terms.

I hereby instruct my attorney that in the event another attorney is "substituted-in" for this matter, that the new attorney receives written notice of this lien from the "substituted-out" attorney with a copy of this lien attached to said notice. I hereby agree that in the event a new attorney is "substituted-in", I shall instruct the new attorney to honor this lien as if it were executed by that attorney and to execute the lien as the new attorney of record.

I declare that I have thoroughly discussed with you, my attorney, all possible sources of funding for the treatment of my injuries including, but not limited to, commercial health insurance, health management organizations, and government programs such as Workers' Compensation and have decided that obtaining medical treatment on a lien is the best option. As such, bills for my treatment will not be submitted to any such health insurance program for payment.

I hereby instruct you, my attorney, to provide the DOCTOR with name (s), address (es), telephone number (s) and claim number (s) of any and all insurance carriers involved in my case. I further agree that in that event I move my residence prior to the final disposition of my case, I shall notify the DOCTOR in writing as to my new address and telephone number. I further agree that I shall instruct my attorney to respond in writing to any request made by the DOCTOR as to the status of my case. I further understand that if neither I nor my attorney cooperate in protecting the DOCTOR's interest, the DOCTOR will not await payment and may declare the entire balance, owed to it, immediately due and payable and I will be required to pay for the services rendered to me by the DOCTOR.

I hereby agree to waive the running of any Statute of Limitations for an additional period of four (4) years as provided in CCP 360.5. I further understand that such payment is not contingent on any settlement, judgment or verdict. I further agree that if an appointment is canceled or rescheduled within 24 hours of the appointment, a charge of $100 for follow up visit and $200 for initial visit will be charged. In addition, I further agree that if the DOCTOR pursues legal action against me to enforce my obligation to pay for the services rendered by the DOCTOR, attorney fees and costs shall be awarded to the prevailing party.

I acknowledge that by my signature that I have read this entire Notice of Lien and that all provisions, rights, and obligations have been explained to me by you, my attorney.

ATTORNEY: PLEASE DATE, SIGN AND RETURN A COPY OF THIS LIEN TO OCEAN SPINE.

The undersigned attorney of record for the above-referenced patient agrees to observe all of the terms of the above Notice of Lien and to withhold such amounts due the DOCTOR from any settlement, judgment, verdict or other recovery as may be necessary to fully compensate the DOCTOR for the services rendered to the above-named patient and to pay such amounts to the DOCTOR.

In addition to your insurance card this information must be fully completed in order for us to courtesy bill your insurance company.

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS

your check is returned by the bank, a $20 service charge will be added to your account. I request that payment of authorized Medicare/ Other insurance company benefits be made to OCEAN SPINE for any services to me by the physician who accepts assignment. Regulations pertaining to Medicare apply. I authorize any holder of medical, or other information about me to release the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers of any information needed for this or related Medicare/ Other Insurance Company claim. I permit a copy of this authorization to be used in place of the original. I understand that it is mandatory to notify the healthcare provider or any other party who may be responsible for paying for my treatment. (Section1128B of the social Security Act and 31U.S.C. 381-3812 provides penalties for witholding this information). Conditional payment of any charges resulting from 3rd party liability will be requested from the insurance company. At the time of settlement of 3rd party liability cases,insured will be responsible for reimbursing the insurance company payments made and the payment in full for any medical charges incurred in this office relating to said inquiry. I understand that payment is my obligation and responsibility, regardless of insurance and other third party involvement. I have read and understand possible finacial responsibility for services rendered and hearby affix signature as ackknowledgement of this understanding.

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 California law, and not by a lawsuit or resort to court process except as California law provides for judicial review or arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided on a court of law before a jury, and instead are accepting the use of arbitration. The execution of this arbitration agreement is not a precondition to receiving medical care.

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 related 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 the mother and the mother’s expected child or children.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician’s partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.

Article 3: Procedures and Applicable Law: A demand for arbitration must communicate 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 rata 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. The parties agree that the arbitrators have the immunity of a judicial officer 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.

The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Section 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrations a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05, however, depositions may be taken without prior approval of the neutral arbitrator.

Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in once proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California 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 California 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, or signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.

Article 6: Retroactive Effect: This agreement is effective as of the first date medical services were provided.

If any provision if 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.

Opioids (narcotics) are used for the management and treatment of moderate to severe pain. Our goal is to relieve distressing pain, with minimal drug side effects, in the hopes of improving quality of life. It is our job to continually re-evaluate your pain experience and respond to unrelieved pain.

1. I will take medication only at the dose and frequency prescribed. I will not take medication in combination with alcohol or other substances.
2. No other pain medications are to be taken unless discussed first with your physician or his/her afflicted physicians at Ocean Spine.
3. No increases in medication will be made without the approval of your physicians.
4. I will not request opioids or any other medicine prescribers other than from Ocean Spine.
5. I will consent to periodic and random drug testing (blood, urine, hair or saliva).
6. I will protect my prescriptions and medications and store them in a secure location. Lost or stolen prescriptions will not be replaced under any circumstances. I will safely dispose of any unused medication to prevent misuse by other members of my household.
7. I will keep my scheduled appointments or cancel/reschedule my appointment at least 24 hours prior to my scheduled time; otherwise, I risk not being given my opioid prescription. Furthermore, I may be discharged from Ocean Spine. due to contract breach.
8. I will share information with family members and other close contacts on how to recognize and respond to an opiate overdose, including administering an opioid antagonist, if necessary.
9. I understand that my treatment may be stopped if any of the following occur:
• if the practitioner feels that opioids are not effective for my pain or my functional activity is not improved.
• I give, sell, or misuse the prescribed medications.
• I develop rapid tolerance of loss of effect from this treatment.
• I develop side effects that are significant in the view of the practitioners.
• I obtain opioids from sources other than Ocean Spine.
• If I miss three (3) scheduled appointments.
10. If the decision is made to discontinue your opioids, you will be given a program to taper off.
11. I understand that if I have any questions or concerns regarding my pain treatment that I will call Patel Spine Care Medical, Inc. Monday through Friday 9:00 am to 5:00 pm at (310) 403-5778.

I have read, understood, and consent to the above guidelines.

Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communication. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.

I understand that telehealth involves the communication of my medical/mental health information in an electronic or technology-assisted format.

I understand that I may opt out of the telehealth visit at any time and that I have the right to access medical care through an in-person, face-to-face visit. This will not change my ability to receive future care at this office.

I understand that telehealth services can only be provided to patients, including myself, who are residing in the state of California at the time of this service.

I understand that telehealth billing information is collected in the same manner as a regular office visit. My financial responsibility will be determined individually and governed by my insurance carrier(s), Medicare, or Medicaid, and it is my responsibility to check with my insurance plan to determine coverage.

I understand that receiving services through telehealth means carries some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand. These risks include but are not limited to:

1. It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures.
2. Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network.
3. Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted by technical failures.

I agree that information exchanged during my telehealth visit will be maintained by the doctors, other healthcare providers, and healthcare facilities involved in my care.

I understand that medical information, including medical records, are governed by federal and state laws that apply to telehealth. This includes my right to access my own medical records (and copies of medical records).

I understand that Skype, FaceTime, or a similar service may not provide a secure HIPAA-compliant platform, but I willingly and knowingly wish to proceed.

I understand that I must take reasonable steps to protect myself from unauthorized use of my electronic communications by others.

The healthcare provided is not responsible for breaches of confidentiality caused by an independent third party by me.

I agree that I have verified to my healthcare provider my identity and current location in connection with the telehealth services. I acknowledge that failure to comply with these procedures may terminate the telehealth visit.

I understand that I have a responsibility to verify the identity and credentials of the healthcare provider rendering my care via telehealth and to confirm that he or she is my healthcare provider.

I understand that electronic communication cannot be used for emergencies or time-sensitive matters.

I understand and agree that a medical evaluation via telehealth may limit my healthcare provider’s ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider’s recommendations—including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit.

I understand that electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependence, etc.).

I understand that my healthcare provider may choose to forward my information to an authorized third party. Therefore, I have informed the healthcare provider of any information I do not wish to be transmitted through electronic communications.

By signing below, I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit.

I understand that there is never a warranty or guarantee as to a particular result of outcome related to a condition or diagnosis when medical care is provided.

To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visit.

I understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communication should be made to the provider’s office or to the existing emergency 911 services in my community.

The purpose of this form is to obtain your consent for a telehealth visit with one of our healthcare providers at Patel Spine Care Medical, Inc.

I certify that I have read and understand this agreement and that all blanks were filled in prior to my signature with the opportunity to have questions answered to my satisfaction.

I certify that I have explained the nature of this agreement to the patient/patient's legal representative. I have answered all questions fully, and I believe that the patient/legal representative (circle one) fully understands what I have explained.

If you have any questions, please contact (310) 403-5778.
Thank you!