Acknowledgement of Receipt of Privacy Practices I certify that I have received a copy of Notice of Privacy Practices. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment of my bills or in the performance of Norco's health care operations. The Notice of Privacy Practices also describes my rights and Norco's duties with respect to my protected health information. The Notice of Privacy Practices is posted at the front counter and on Norco’s website at www.norcomedical.com. Norco reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail, asking for one at the time of my next appointment, or accessing Norco's website.

Customer Release of Information/Authorization to Assign Benefits I hereby request payment of my authorized Medicare or other carrier benefits to be made on my behalf to Norco Medical (Norco) for any products and services that they furnish me. I further authorize that a copy of this agreement can be used in place of the original and authorize Norco or any holder of medical information about me to release to the Medicare (CMS), any other insurer and/or their agents any information needed to determine these benefits. I authorize the release of medical information about me to Norco. I also authorize Norco to release medical information about me to nursing agencies or physicians involved in my care, and any other regulatory or accrediting body governing Norco's scope of service. Norco bills third party payors as a courtesy; I understand that I am fully responsible for all deductibles, coinsurances, and disallowables and that a prescription from my physician does not guarantee my insurance carrier's participation for payment.

Customer Agreements I hereby agree to the terms below regarding the rental/purchase of equipment and/or supplies from Norco:

• Norco's standard rental billing cycle is in one month. Customer acknowledges that Norco bills for rental equipment at the beginning of the rental cycle and DOES NOT prorate equipment rental.
• I understand that I am financially responsible to Norco for all charges incurred through the term of this agreement.
• I hereby acknowledge receiving full instructions and have demonstrated my understanding in the proper use and care of the equipment and/or supplies that have been delivered to me and are described on Norco's shipper or picking ticket.
• I understand that I will be held responsible for any piece of my durable medical equipment and/or supplies that have been damaged, defaced, lost, or destroyed as a result of neglect, abuse, or misuse of the item.
• I agree to make arrangements within two weeks of entering either a hospital or a skilled nursing facility or when the medical necessity for the equipment no longer exists to return all equipment to Norco.

I have read the above sections and understand the Customer Agreements noted on this form. I acknowledge that the Norco Patient Orientation Handbook has been provided online for my review at www.norcomedical.com/patient-referral. I also understand that in the event my insurance carrier denies payment for any reason, I am responsible for payment to Norco for the items delivered.