• I consent to the downloading of my E-prescribing history.
• I give permission for Arthritis & Rheumatic Care to submit claims to my insurance carrier and receive payment for services rendered.
• I understand that I am ultimately responsible for the bills for services rendered.
• I have completed these forms to the best of my knowledge and ability. If there are any changes to my information, I will report them to the office.

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment, directly or indirectly.
• Obtain payment from third party payers.
• Conduct normal health care operations such as quality assessments and physician certifications.

I have received, read and understand the Notice of Privacy Practices document containing a more complete description of the uses and disclosures of my health information. I understand that Arthritis & Rheumatic Care, LLC has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below for a current copy of the Notice of Privacy Practices document.

I give my permission for Arthritis & Rheumatic Care, LLC and its assigns to release information regarding my health, my results, my appointments to the following individuals:

Telemedicine, also referred to as telehealth medicine, is the real-time, audio-visual visit between a provider and patient. It can be used as an alternative to traditional
in-person care delivery and, in certain circumstances, can be used to deliver care including the diagnosis, consultation, treatment, education, care management and
patient self-management.

You talk to your provider with a phone, computer or tablet. Sometimes, you use videos so you and your provider can see each other.

You don't have to go to the clinic or hospital to see your providers. It also reduces your risk of getting sick from other people.

No transportation time or costs, reduce wait time, and more detailed and personalized care compared to telephone calls.

You and your provider will not be in the same room, so it may feel different from an office visit. Your provider cannot examine you as closely as they might at an in-
office visit. Your provider may decide that you still need an office visit. Technical problems may interrupt or stop your visit before you are done.

We will not record visits with your provider. If people are close to you, they may hear something you do not want them to know. You should be in a private place so
other people cannot hear you. Your provider will tell you if someone else from their office can hear or see you. We use HIPAA compliant, encrypted telehealth
technology that is designed to protect your privacy. If you use the internet for telehealth, use a network that is private and secure. There is a very small chance that
someone could use technology to hear or see your telehealth visit.

Telehealth is best suited for interactions with established patients who do not require a physical exam or lab work.

Telehealth is not suited for a physical exam or lab testing.

The decision is up to you and your provider. Find out what options are available to you by calling the practice.

You can stop using telehealth any time, even during a telehealth visit. You can still get an office visit if you no longer want a telehealth visit. If you decide you do not
want to use telehealth again, call 201-975-2400 and say you want to stop.

What you pay depends on your insurance. If your providers decide you do need an office visit in addition to your telehealth visit, you may have to pay for both visits.

Only if you want to use telehealth.

If you sign this document, you agree that: We talked about the information in this document. We answered all your questions. You want a telehealth visit.

LIST ALL OF YOUR CURRENT MEDICATIONS INCLUDING PRESCRIPTIONS, HERBALS, VITAMINS, SUPPLEMENTS AND OVER THE
COUNTER MEDICATIONS

IF MORE SPACE IS NEEDED, PLEASE ATTACH AN ADDITIONAL SHEET.

Thank you for choosing our practice for your healthcare needs. It is our goal to provide you with the
highest quality healthcare services possible. We ask you please read and understand your financial
responsibilities prior to receiving service.

Arthritis & Rheumatic Care, LLC endeavors to verify your benefit information as a courtesy to you, our
Patient. We carefully document the information provided by your Carrier regarding coverage,
deductibles, coinsurance and maximum out of pocket expense, however, please keep in mind that this is
an estimate and is not a guarantee of payment. Your insurance company makes the final decision on
coverage once the claim is received.

• Payment is expected as services are rendered. Copays, deductibles and coinsurance amounts
  are collected at the time of service.
• I am financially responsible for any amount not covered by my insurance plan, including but not
  limited to co-payments, deductibles, co-insurance and non-covered services. If my insurance
  company denies payment or requests information from me that causes a processing delay, I
  understand the balance becomes my direct obligation.
• I understand that if my plan requires a referral, it is my sole responsibility to obtain that referral in
  advance Please note, a physician's prescription is not a valid referral form. If services are denied
  because I did not obtain a referral, I will be responsible for the bill.
• In the event my account is sent to a collection agency, I agree to pay all associated collection fees
  and legal expenses.
• I will provide updated copies of my insurance cards (front and back) at the time of service.
• There is a $35 fee for checks returned by my bank for any reason.
• Services performed by other providers are subject to their financial policies and not those of
  Arthritis & Rheumatic Care.

Assignment of Benefits: I hereby authorize any insurance carrier, including Medicare, to make payment
directly to Arthritis & Rheumatic Care for any services rendered to me or my covered dependents of any
amounts otherwise payable to me toward the reimbursement of any medical expenses incurred at this
facility. I understand that I am ultimately financially responsible for payment of all services regardless of
any insurance coverage that I may have. A photocopy of this authorization shall be considered as
effective and valid as the original.

I understand and agree that:

ARTHRITIS &
RHEUMATIC
CARE

Release of Medical Records and Information: I hereby authorize the release of any Protected Healthcare Information (PHI) to any involved insurance company, or other authorized third parties involved in my case unless I have specifically instructed otherwise.

I understand that Arthritis & Rheumatic Care does not participate with my insurance plan. I have opted to receive services from this non-participating provider and have agreed to be responsible for the bill. I understand that payment is expected as services are rendered.

I understand that Arthritis & Rheumatic Care uses Freed AI software to capture and transcribe visit notes.

I understand and agree to these terms and conditions: