(Please give your insurance card to the receptionist)

I understand that if the above is not true or if it is determined that I am not eligible under the terms of my Medical Insurance Plan, I am liable for all charges for services rendered. Also, if the above is not true, I agree to pay in full for services received within O days of receiving a bill from Tri- City Primary Care. Fees for Services rendered are payable at the time of service unless previous arrangements have been made. We accept assignments for Medicare and most insurance plans. I hereby authorize medical and billing information to be released to my insurance company.

Please List all individuals that are authorized to receive medical information either verbal or written

Tri-City Primary Care/North County Endocrinology Associates
Privacy Officer (760) 940-3030
Effective Date: October 1, 2018

This notice described how medical information about you may be used and disclosed and how you can get access to this
information.

We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We
make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable
other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health
plan and to enable us to meet our professional and legal obligations to operate this medical practice properly. We are required by
law to maintain the privacy of protected health information (PHI), to provide individuals with notice of our legal duties and privacy
practices with respected to PHI, and to notify affected individuals following a breach of unsecured PHI. This notice describes how we
may use and disclose your medical information. It also describes your rights and our legal obligations with respect to your medical
information. If you have any questions about this Notice, please contact our Privacy Office listed above.

1. Treatment: The provision, coordination, or management of health care and related services by one or more healthcare
providers, including the coordination of management of health care by healthcare provider with a third party; consulting
between healthcare providers relating to a patient; or referral of a patient for health care from one health care provider to
another. We may disclose medical information to our employees and others who are involved in providing the care you
need.

2. Payment: Reimbursement for the provision of healthcare, which includes but is not limited to: billings, claims management,
collection activities, obtaining payment under a contract for reinsurance, and related health care data processing. Tri- city
primary care will only use and disclose medical information about you to obtain payment for the services we provide. We
may also disclose information to other health care provider to assist them in obtaining payment for services they have
provided to you.

3. Health Care Operations: Conducting quality assessment and improvement activities., including outcomes and evaluation
and development of clinical guidelines, (provided that the obtaining of generalized knowledge is not the primary purpose of
any studies resulting from such activities); population - based activities relating to improving health or reducing health care
cost, protocol development, case management, and care coordination, contracting of healthcare providers and patients
with information about treatment alternatives; and related functions that do not include treatment. We may also share
your medical information with our "Business Associates," such as our billing services that perform administrative services
for us. We have a written contract with each of these associates that contains terms requiring them to protect the
confidentiality and security of your medical information.

4. Appointment Reminders: We may use and disclose medical information to contract and remind you about appointments.
If you are not home, we may leave this information on your answering machine or in a message left with the person
answering the phone.

5. Sign-in Sheet: We may use and disclose medical information about you by having you sign in when you arrive at our office.
We may also call out your name when we are ready to see you.

6. Notification and Communication with Family: We may disclosure your health information to notify or assist in notifying a
family member, your personal representative or another person responsible for your care about your location, your general
condition or, unless you had instructed us otherwise, in the event of your death. In the event of disaster, we may disclose
information to a relief organization so that they coordinate these notification efforts. We may also disclose information to
someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will
give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster
even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable to agree
or object, our health professional with use their best judgement in communication with your family and others.

7. Marketing: Provided we do not receive any payment for making these communications, we may contact you to encourage
you to purchase or use products or services related to your treatment, case management or care coordination, or to direct

or recommend other treatments, therapies, healthcare providers or settings of care that may be of interest to you. We may similarly describe products or services provided by this practice and tell you which health plans we participate in. We may receive financial compensations to talk with you face-to-face, to provide you with small promotional gifts, or to cover your cost of reminding you to take and refill your medication or otherwise communicate about a drug or biologic that is currently prescribed for you, but other if you either: (1) have a chronic and seriously debilitating or life-threating condition and the communication is made to educate or advise you about treatment options and otherwise maintain adherence to a prescribed course of treatment, or (2) you are a current health plan enrollee and the communication is limited to the availability of more cost-effective pharmaceuticals.

8. Sale of Health Information: We will not sell your information without your prior written authorization. The authorization will disclose that we will receive compensation of your health information if you authorize us to sell it, and we will stop any future sales of your information to the extent that you revoke that authorization.

9. Required by law: As required by law, we will use and disclose your health information, but we will limit our use or disclosure to the relevant requirements of the law. When the law requires us to report, abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities.

10. Public Health: We may, and are sometimes required by law to, disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problem with products and reactions to medications; and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgement, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.

11. Health Oversight Activities: We may and are sometimes required by law, to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to limitations imposed by federal and California Law.

12. Judicial and Administrative Proceedings: We may, and are sometimes required by law, to disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court administrative order.

13. Law Enforcement: We may, and are sometimes required by law, to disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes.

14. Coroners: We may, and are often required by law, to disclose your health information to coroners in connection with their investigations of deaths.

15. Organ or Tissue Donation: We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.

16. Public Safety: We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

17. Proof of Immunization: We will disclose proof of immunization to a school where the law requires the school to have such information prior to admitting a student if you have agreed to the disclosure on behalf of yourself or dependent.

18. Specialized Government Functions: We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.

19. Workers Compensation: We may disclose your health information as necessary to comply with worker's compensation laws. For example, to the extent your care is covered by worker's compensation, we will make periodic reports to your employer about your condition. We are also required by law to report cases of occupational injury or occupational illness to the employer or workers' compensation insurer.

20. Change of Ownership: In the event that this medical practice is sold or merged with another organization, your health information/records will become the property of the new owner. Although you will maintain the right to request copies of your health information, PHI may be transferred to another physician or medical group.

21. Breach Notification: In the case of a breach of unsecure PHI, we will notify you as required by law. In some circumstances our Business Associates may provide the notification

22. Research: We may disclose your health information to researches conducting research with respect to which your written authorization is not required as approved by an Institutional Review Board or privacy board, in compliance with governing law.

Except as described in this Notice of Privacy Practices, Tri-City Primary Care, consistent with its legal obligations, will not use or disclose health information which identifies you without your written authorize. If you do authorize Tri-City Primary Care to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

1. Right to Request Special Privacy Protections: You may ask us to limit how your PHI is used and disclosed (i.e. in addition to our rules as set forth in this Notice) by submitting a written "Request for Restriction on Use, Disclosure" form to us (i.e. you may not want us to disclose your surgery to family members or friends involved in paying for our services or providing your home care). If we agree to these additional limitations, we will follow them except in an emergency where we will not have time to check for limitations. Also, in some circumstances we may be unable to grant your request (i.e. we are required by law to use or disclose your PHI in a manner that you want restricted, you signed an Authorization Form, which you may revoke, that allows us to use or disclose your PHI in the manner you want restricted; in an emergency).

2. To Inspect and Copy: You have the right to see and get a copy of your PHI including, but not limited to, medical and billing records by submitting a written request to our Privacy Officer. Original records will not leave the premises, will be available for inspection only during our regular business hours, and only if our Privacy Officer is present at all times. You may ask us to give you the copies in a format other than photocopies (and we will do so unless we determine that it is impractical) or ask us to prepare a summary in lieu of the copies. We may charge you a fee not exceed state law to recover our costs (including postage, supplies, and staff time as applicable, but excluding staff time for search and retrieval) to duplicate or summarize your PHI. We will not condition release of the copies on summary of payment of your outstanding balance for professional services if you have one). We will comply with Federal Law to provide your PHI in an electronic format within the 30days, to Federal specification, when you provide us with proper written request. Paper copy will also be made available. We will respond to requests in a timely manner, without delay for legal review, or, in less than thirty days if submitted in writing, and in ten business days or less if malpractice litigation or pre-suit production is involved. We may deny your request in certain limited circumstances (i.e. we do not have the PHI, it came from a confidential source, etc.). If we deny your request, you may ask for a review of that decision. If we required by law, we will select a licensed health-care professional (other than the person who denied your request initially) to review the denial and we will follow his or her decision. If we select a licensed healthcare professional who is not affiliated with us, we will ensure a Business Associate Agreement is executed that prevents re-disclosure of your PHI without your consent by that outside professional.

3. To Request Amendment / Correction: if another doctor involved in your care tells us in writing to change your PHI, we will do so as expeditiously as possible upon receipt of the changes and will send your written confirmation that we have made the changes, If you think PHI We have about you is incorrect, or that something important is missing from your records, you may ask us to amend or correct it (so long as we have it) by submitting a "Request for Amendment / Correction" form to our Privacy Officer. We will act on your request within 30 days from receipt but we may extend our response time (within the 30-day period) no more than once and by no more than 30 days, or as per Federal Law allowances, in which case we will notify you in writing why and when we will be able to respond. If we grant your request, we will let you know within five business days, make the changes by noting (not deleting) what is incorrect or incomplete and adding to it the changed language, and send the changes within 5 business days to persons you ask us to and persons we know may rely on incorrect or incomplete PHI to your detriment (or already have). We may deny your request under certain circumstances (i.e. it is not in writing, it does not give a reason why you want the change, we did not create the PHI you want changed, and the entity that did can be contracted, it was compiled for use in litigation, or we determine it is accurate and complete). If we deny your request, we will (in writing within 5 business days) tell you why and how to file a complaint with us if you disagree, that you may submit a written disagreement with our denial (and we may submit a written rebuttal and give you a copy of it), that you may ask us to disclose your initial request and our denial when we make future disclosure of PHI pertaining to your request, and that you may complain to us and the U.S. Department of Health and Human Services.

4. To an Accounting of Disclosures: You may ask us for a list of those who got your PHI from us by submitting a "Request for Accounting of Disclosures" for to us. The list will not cover some disclosures (i.e. PHI given to you, given to your legal representative, given to others for treatment, payment or health-care-operations purposes). Your request must state in what form you want the list (i.e. paper or electronically) and the time period you want us to cover, which may be up to but not more than the last six years. If you ask us for this list more than once in a 12-month period, we may charge you a

reasonable, cost-based fee to respond, in which case we will tell you the cost before we incur it and let you choose if you want to withdraw or modify your request to a void the cost.

5. To Request Alternative Communications: You may ask us to communicate with you in a different way or at a different place by submitting a written "Request for Alternative Communication" form to us. We will not ask you why and we will accommodate all reasonable requests (which may include: to send appointment reminders in closed envelopes rather than by postcards, to send your PHI to a post office box instead of your home address, to communicate with you at a telephone number other than your home number). You must tell us the alternative means or location you want us to use and explain to our satisfaction how payment to us will be made if we communicate with you as you request.

6. To Complain or Get More Information: We will follow our rules as set forth in this Notice. If you want more information or if you believe your privacy rights have been violated (i.e. you disagree with a decision of ours about inspection/copying, amendment/correction, accounting of disclosures, restrictions or alternative communications), we want to make it right. We never will penalize you for filing a complaint. To do so, please contact:

TRICITY HEALTHCARE DISTRICT
CHIEF COMPLIANCE OFFICER
4002 VISTA WAY
OCEANSIDE, CA 92056

Or file a formal, written complaint within 180 days with:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Ave., S.W.
Washington, DC 20201
877.696.6775

I have received, read and understood the full and complete Notice of Privacy Practices. I understand that I may request restrictions on disclosures, a history of non-routine disclosure access to medical records, and amend protected health information. However, Tri-City Primary Care does not have to grant access to or amend your medical record if it in our best interest as determined by a physician.

Tri- City Primary Care is a provider for many insurance plans and will be listed in your group's list if we are participating in your plan. We will bill your insurance directly and receive payment directly from them. However, to avoid any confusion, be aware that we do expect payment of any applicable deductible, co-payments or co- insurance amounts at the time of service. Also, any services that your insurance will not cover are your responsibility.

If your insurance requires prior authorization for any of your treatment here, and if this authorization has not been obtained before your visit, you will be expected to pay for all charges incurred. If your insurance subsequently authorizes today's services, your payment will be refunded upon receipt of insurance payment.

If we are not a participating provider for your insurance plan, we will still bill your insurance directly if you have provided us in complete information to do so, you may receive statement for the entire charge prior to your insurance paying. You may wait to pay us until after the insurance has paid its portion providing the insurance company pays within 30 days.

If you do not have insurance, payment is expected at the time of service. We accept Visa and Mastercard for your convenience. If payment in full is not possible at the time of service, payment plans are available and can be arranged in our Business Office upon your request.

If you need our doctor to complete forms, (such as for disability, Department of Vehicles, Assisted Living Admission Forms or other physician report forms), there will be a $75.00 fee per form.

Statements are mailed monthly to patients with an outstanding balance. We may assess interest @ the rate of 1% per month on all accounts over 60 days. If you are unable to pay your balance within 30 days, please contact the Billing Office at (760) 940-7000 to make payment arrangements, unless a payment schedule already exists.

If you must cancel your appointment, please give us at least 24-hours' notice so we can schedule another person in your place. There is a Missed Appointment Fee of $40.00 charged for appointments not cancelled with 24-hours' notice. This fee will be waived if a phone call is received within the specified timeframe or if documentation of an emergency can be provided.

Billing Office Hours are 8:30 A.M. to 4:00 P.M., Monday through Friday. If you reach our voicemail, please leave a detailed message and we will return your call as soon as possible.

Thank you for choosing Tri-City Primary Care.

I have read and understand the Tri - City Primary Care financial and claims filing policies.

We are committed to providing you with the very best of healthcare. Please read this form and sign at the bottom.

Payment for services is due at the time of service. We accept cash, checks, Mastercard and Visa. We will be glad to file your insurance claims if you are a member of a plan with which we are contracted.
Please Remember:

• Your insurance is a contract between you, your employer and the insurance company.
• Not all services are a benefit of your contract.
• Non-covered services are your responsibility.
• There may be an invoicing charge of $25.00 if your co-pay or other fees are not paid at the time of service.

Written correspondence for various purposes is available fee.
Form Fees:

• DMV Forms (excluding Handicap placard forms) $75.00
• Other detailed Forms $75.00

24-hour notice is required for cancellations. Missed appointments or less than 24-hour notice will be assessed. The following charges are to partially recover our staffing costs and reserved physician's time.

• New Patient Missed Appointment $100.00
• Follow-up Missed Appointments $40.00

I have read and understand the above statements and agree to abide by these policies.

Jamil B Alkhaddo, MD
Diabetes, Endocrinology, and Metabolism
6185 Paseo Del Norte
Carlsbad, Ca 92011
Phone: 760-536-8397
Fax: 760-536-8463

PLEASE FAX RECORDS TO: (760) 267-9123

NOTICE TO REQUEST FACILITY: Please include the following information:
1: Immunization records (both EMR and paper records)
2: Problem List (both EMR and paper records)

Duration: This Authorization is effective for 1 year from the date listed above unless otherwise noted below.

Attention: This fax is intended to be for the use only of the named recipient, and may contain information that is confidential or privileged. If you are not the intended recipient you are hear by notified that any disclosure, copying distribution or use of the contents of this message is strictly prohibited. If you have received this fax in error or not the named recipient, please notify us immediately by contacting the sender at (760) 940-7000 and destroy all copies of this fax. Thank you.