New Patient Package 9328 E. Raintree Dr. Scottsdale, AZ 85260 5520 W. Chandler Blvd. #3 Chandler, AZ 85226 Phone: (602) 266 - 8463 Fax: (602) 266 - 0122 www.endoassocaz.net

Endocrinology Associates, P. A.

As a new patient, the following is required for your visit: 1. Insurance card, state issued ID with current address or proof of address. 2. You must bring all pertinent medical records to your visit which includes recent labs, Thyroid US reports, scans, and actual films(films can be picked up from imaging center). This information is critical for a prompt evaluation. 3. If you have TriCare, your referring physician MUST send us your referral prior to your appointment. You cannot see the physician without the referral. 4. If you are a non-english speaking patient, please bring a reliable interpreter to your appointment. (Si usted no habla ingles, traiga por favor un interprete confiable a su cita.) 5. Bring a list of your medications including dosage and frequency.

Patient Information

Email Address: _______________________________

Patient Name:

Address:

SSN: ____________________

Marital Status: Single: Married:

City: State: Zip Code: Phone #: Work #:

Gender:

Male: Female:

Date of Birth: Age:

Spouse Name: Phone#:

Nearest Relative:

Responsible Party Information

Phone#:

Name: SSN:

Relationship to Patient: Self Child Spouse Other Date of Birth:

Referring Physician

Name:

Information

Address:

City: State: Zip Code:

Phone #:

Primary Insurance Information

Insurance Co:

Secondary Insurance Information

Insurance Co:

Employer: Employer:

Policy #: State: Zip Code: Policy #: State: Zip Code:

Group Claim #: Group Claim #:

Additional Insurance Information

Insurance Co:

Pharmacy Information

Name:

Employer: Address:

Policy #: State: Zip Code: Number:

Group Claim #:

Name: Date of Birth: Age: Occupation:

Race: Caucasian: Latino/Hispanic: African American: Asian: Other:

Primary Doctor: Referring Doctor:

Reason for Today's Visit:

Past Illnesses: (i.e. High Blood Pressure, Diabetes, Hypothyroid, Sleep Apnea)

Marital Status Married Single Divorced Widowed Tobacco Use: None Current Quit How much are/did you smoke per day: Caffeine Use: Yes

No Quit How much caffeine per day:

Alcohol Use: Yes No Quit How much alcohol per day: Exercise: Cardio Weight Resistance Both Number of times weekly: Past Surgeries (Please Add Year in selection):Thyroidectomy: Hysterectomy: Tonsillectomy: Tubal Ligation/Ablation: Appendectomy (Appendix Removed): Hernia Repair: Cholecystectomy (Gall Bladder): CABG (Open Heart Surgery): Breast Augmentation: Cataract Surgery: Pituitary Tumor Removal: Adrenal Tumor Removal: Knee Arthroscopy: Gastric Bypass: Other (Specify Surgery and Year): Family Illnesses (i.e. Parents, Brothers, Sisters, Children) Check all that apply:

Diabetes Heart Failure Pituitary Disease High Blood Pressure Hyperthyroidism Osteoporosis Multiple Sclerosis Autoimmune disease Hypothyroidism Kidney Stones Vitiligo Enlarged thyroid/goiter High Calcium Heart Disease High Cholesterol Cancer (what type?) Other Illness Current Medications (include vitamins, herbs, and over-the-counter supplements)

Name: Dose: Times per day:

Name:

Name:

Name:

Name:

Name:

Name:

Name:

Drug Allergies

Dose:

Dose:

Dose:

Dose:

Dose:

Dose:

Dose:

Times per day:

Times per day:

Times per day:

Times per day:

Times per day:

Times per day:

Times per day:

Name: Reaction: Name: Reaction:

Last Bone Density: Results: Normal Osteopenia Osteoporosis

Medication Treatment? Yes No What Medication? How Long?

History of Fractures? Yes No What Area?

Females Only Age Menstrual Cycle Started:

Did you have diabetes while you were pregnant?

Yes

# of Pregnancies: # of Births: # of Miscarriages:

No Did you have thyroid problems while you were pregnant or 1 year after birth? Yes No If you are still menstruating, are your menstrual cycles regular? Yes No N/A Postmenopausal Women Only: Age you stopped your menstrual cycle? Was it due to a hysterectomy? Yes No Were your menstrual cycles regular prior to menopause? Yes No Have you ever been on hormone replacement therapy? Yes No If yes, how many years?

New Patient Package 9328 E. Raintree Dr. Scottsdale, AZ 85260 5520 W. Chandler Blvd. #3 Chandler, AZ 85226 Phone: (602) 266 - 8463 Fax: (602) 266 - 0122 www.endoassocaz.net

Endocrinology Associates, P. A.

Patient Name: Date of Birth:_________

Gender: Male Female

Please Check the box indicating that you have experienced the following symptoms in the past 6 months:

Constitutional: Fever Chills Headache

Eyes:

Double Vision Blurred Vision Sensitivity to light

Ear Nose Mouth Throat:

Nasal Congestion Earache Sore Throat Nasal Discharge

Ringing in Ears Trouble Swallowing

Neck:

Breasts:

Respiratory:

Cardiovascular:

Gastrointestinal:

Genitourinary:

Skin:

Musculoskeletal:

Neurological:

Psychiatric:

Hematologic:

Endocrine:

Neck Pain Neck Stiffness Swollen Glands A Lump or Swelling

Nipple Discharge Change in breast skin Breast Lump Breast Pain

Breast Enlargement

Cough Wheezing Coughing up Sputum Shortness of Breath

Difficulty Breathing

Chest Pain Palpitations Cold Hands or Feet Shortness of breath with Exertion

Pain in legs with walking Trouble laying flat in bed

Nausea Vomiting Diarrhea Abdominal Pain

Black Stools Blood in stool

Pain with urination Burning on urination Decrease in urine flow Blood in urine

Urination at night Going Frequently Sexual Dysfunction

Rash Itching Hives Bruising

Eczema Lesions

Back Pain Muscle pain Joint pain Leg pain

Foot Swelling Joint Stiffness

Difficulty Walking Confusion Fainting Dizziness

Numbness Tingling Speech Difficulty Tremors

Anxiety Fatigue Sleep Disturbances Decreased Energy

Depression

Easy Bleeding Tendency Easy Bruising

Frequent urination Frequent thirst Temperature Intolerance

Other Symptoms

New Patient Package 9328 E. Raintree Dr. Scottsdale, AZ 85260 5520 W. Chandler Blvd. #3 Chandler, AZ 85226 Phone: (602) 266 - 8463 Fax: (602) 266 - 0122 www.endoassocaz.net

Endocrinology Associates, P. A.

I hereby authorize payment directly to the attending physician for medical and/or surgical benefits, if any from the insurance carrier to Endocrinology Associates P.A.; if paying cash, I am responsible to pay at the time of service.

Patient name (Please Print) Date of Birth

Signature of Patient and/or Legal Guardian Date

Endocrinology Associates' Witness Date

I authorize the following person(s) to have access to my medical information.

Relationship

Relationship

Please list a phone number(s) that Endocrinology Associates P.A. may contact to leave detailed medical information, appointment reminders and no show follow up .

Phone number: ___________________ Alternate phone number: __________________

Endocrinology Associates, P.A.

PATIENT FINANCIAL RESPONSIBILITY STATEMENT Thank you for choosing Endocrinology Associates, P.A., as your healthcare provider. The medical services you seek imply an obligation on your part to ensure payment in full is made for services received. This Patient Financial Responsibility Statement (“Statement”) will assist you in understanding that financial responsibility. Feel free to ask if you have any questions. If someone else (parent, spouse, domestic partner, etc.) is financially responsible for your expenses or carries your insurance, please share this Statement with them, as it explains our practices regarding insurance billing, copayments, and patient billing. By your acknowledgement of this Statement and/or by receipt of medical services from Endocrinology Associates, P.A. (“Endocrinology Associates”), you agree: 1. You acknowledge and agree to all FINANCIAL POLICIES of Endocrinology Associates. Questions about these policies may be addressed to the front desk staff. These policies may be changed from time to time by Endocrinology Associates, without notice. If there is any conflict between the FINANCIAL POLICIES and this PATIENT FINANCIAL RESPONSIBILITY STATEMENT, the FINANCIAL POLICIES shall control. 2. You are ultimately responsible for all payment obligations arising out of your treatment or care and guarantee payment for these services. You are responsible for deductibles, co-payments, co- insurance amounts or any other patient responsibility indicated by your insurance carrier or our FINANCIAL POLICIES, which are not otherwise covered by supplemental insurance. All new patients are asked to pay a 250.00 deposit if you have a deductible of 1500.00 or more that has not been met. This deposit will apply towards your co-payment, co-insurances and deductibles that are applied to your services. Co-insurances and deductibles are most commonly applied to our imaging and laboratory services; however this is not always the case. There may be a co-payment on your visit and a co-payment on your imaging and laboratory services. Coverage varies per insurance companies and from policy to policy. Please contact your insurance carrier for your exact coverage. 3. You are responsible for knowing your insurance policy. For example, you will be responsible for any charges if any of the following apply: (i) your health plan requires prior authorization or referral by a primary care physician (PCP) before receiving services at Endocrinology Associates , and you have not obtained such an authorization or referral; (ii) you receive services in excess of such authorization or referral; (iii) your health plan determines that the services you received at Endocrinology Associates are not medically necessary and/or not covered by your insurance plan; (iv) your health plan coverage has lapsed or expired at the time you receive services at Endocrinology Associates ; or (v) you have chosen not to use your health plan coverage. If you are not familiar with your plan coverage, we recommend you contact your carrier or plan provider directly. 4. You will be required to follow all registration procedures, which may include updating or verifying personal information, presenting verification of current insurance, and paying any co-pays or other patient responsibility amount at each visit. Your card or other insurance verification must be on file for your insurance to be billed. If we do not have your card on file,

or are unable to verify your eligibility for benefits, you will be considered a self-pay patient. As a self-pay patient, our fee quoted to you is expected to be paid in full at the time of service. The fee quoted to you at the time of service is an estimate only. Additional orders may be added as medically necessary. You will be billed for any additional charges. If the insurance card or other necessary information is furnished after the visit, we may file a claim with your insurance; and, if paid in full by your insurance, you will be reimbursed. If you are not prepared to make your co-pay or other patient responsibility amount, your visit may be rescheduled by Endocrinology Associates. 5. We may verify your insurance benefits or submit your claim to your insurance carrier as a courtesy to you. You agree to facilitate payment of claims by contacting your insurance carrier when necessary. Without waiving any obligation to pay, you assign to Endocrinology Associates, for application onto your bill for services, all of your rights and claims for the medical benefits to which you, or your dependents are entitled, under any federal or state healthcare plan (including, but not limited to, Medicare or Medicaid), insurance policy, any managed care arrangement or other similar third-party payer arrangement that covers health care costs and for which payment may be available to cover the cost of the services provided to you. You authorize Endocrinology Associates and associated physicians, staff, and hospitals to release patient information acquired in the course of your examination and/or treatment including but not limited to any and all medical records, notes, test results, x-ray reports, MRI reports or other documents related to your treatment (including itemization of any charges and payments on my account) that is deemed necessary to process this claim to the necessary insurance companies, third party payers, and/or other physicians or health care entities as they require to participate in your care. It is important to notify us as soon as possible of any changes related to your insurance coverage. Failing to do so may result in unpaid claims, and you will be responsible for the balance of the claim. Endocrinology Associates does not accept responsibility for incorrect information given by you or your insurance carrier regarding your insurance benefits or benefit plans. 6. If your insurance carrier does not remit timely payment on your claim, you will be responsible for payment of the charges within the terms set forth herein. Once your insurance carrier processes your claim, we will bill you for any remaining patient responsibility deemed by your insurance carrier. If any payment is made directly to you for services billed by us, you agree to promptly submit same to Endocrinology Associates unt i l your patient account is paid in full. If you make a payment that results in a surplus on your account, you authorize Endocrinology Associates to apply the overpayment to any other account for which you are financially responsible, including your account, a member of your family’s or dependent’s account, or on any account for which you are a financially responsible party, and any remaining balance will be returned to the payer 7. You will be mailed a billing statement that contains the total cost of your service(s) or procedure(s) received during your visit(s). You may generally expect this billing statement within twenty (20) days after your insurance company has responded to a submitted claim. You must notify us of any errors or objections to the billing statement within thirty (30) days or they will be deemed accurate, and the fees and expenses shall be deemed reasonable and necessary for the services incurred. If there is a problem with your account, it is your responsibility to contact the Patient Accounts Staff to address the problem or to discuss a workable solution. 8. Whether or not you have insurance or are self-pay, payment of any account balance is due within thirty (30) days of receipt of your billing statement. If you need to make special arrangements for payment, you may contact our Patient Accounts Staff to determine if you are eligible for a mutually agreeable alternative payment plan. Partial payments may be accepted and applied, without waiver, at the discretion of Endocrinology Associates. Acceptance of any partial payment shall not extend any time period, cure any default, or be deemed to satisfy any remaining balance due. If any balance on your account is over thirty (30) days past due, your account will be in default and may be referred to a

collection agency. The balance of any account not paid within ninety (90) days will begin to accrue interest at the rate of 1.5% per month or the maximum allowed by applicable law, whichever is lower. For small balances, between $4.01 to $25.00, we may stop sending billing statements any time after the initial statement, but you understand that the amount shall remain due and owing until paid in full. 9. We accept payment by check, cash, money order, debit cards or credit cards (Visa, MasterCard, Amex or Discover card). Payment by Check. If payment is made by check and it is returned or declined for any reason, your account will be charged a surcharge of $35.00 or up to the applicable state maximum legal limits, whichever is lower, in addition to any costs assessed or charged by any depository institution. When you pay by check you also authorize Endocrinology Associates, if your check is dishonored or returned for any reason, to electronically debit your account for the amount of the check plus a processing fee of up to the state maximum legal limits (plus any applicable sales tax). PLEASE NOTE: The above language authorizes an electronic debit to your account for the amount of the check plus the state-allowed recovery fee. In accordance with the rules of the National Automated Clearing House Association, this authorization is to remain in effect until Endocrinology Associates has received written notice of termination in such time and in such manner to afford us a reasonable opportunity to act on it. This does not, however, mean that Endocrinology Associates cannot collect a returned check fee by other means. 10. Managed Care (HMO, PPO, etc.). All managed care co-payment amounts are due at the time of service. If your insurance plan requires a referral authorization from a primary care physician, you are responsible for presenting this at your initial visit. If you request an office visit without a referral authorization, your insurance plan may deem this as “out of network” or “non-covered” treatment, and you will be responsible for a larger amount or all of the charges. You acknowledge that it is your responsibility to be aware of what services are covered and you agree to pay for any service deemed to be non-covered or not authorized by the plan.

11. Medicare. Endocrinology Associates is a participating provider with the Medicare program and accepts as payment the Medicare allowable, patient deductible and/or 20% co-insurance. Medicare or secondary carriers do not cover some procedures and supplies. Please make certain you understand which aspects of your treatment are covered before proceeding. You understand that you will be responsible for your annual deductible, the co-payment, and any non-covered services specified by Medicare. We may submit a claim to any supplemental plan as a courtesy to you, so long as you provide all necessary policy information.

12. Medicaid. If you are a Medicaid patient, you must present a valid eligibility card at the time of registration and prior to the time of service. Your eligibility status will be verified monthly. Without verification of coverage, you will be responsible for the entire balance of your account. As a courtesy to you, your account will be billed to Medicaid when we receive all necessary information. You are responsible for non-covered portions and spend down requirements associated with your individual coverage. If at any time you are not eligible for Medicaid coverage and wish to be seen, you will be treated as a self-pay patient and must make payment at the time of service.

13. Workers’ Compensation Cases. Charges for services incurred as a result of a verified work- related injury will be treated as workers’ compensation, and we will bill the workers’ compensation carrier as a courtesy. You must provide necessary information to bill the carrier. You are responsible for the completion of information with the employer and approval of the workers’ compensation claim. In case your workers’ compensation claim is denied, you will also provide us with your medical insurance information. If your claim is denied, we will bill your regular medical insurance carrier. When the claim is no longer pending and any portion of your claim is ultimately resolved against you by workers’ compensation and your medical insurance, you will be required to pay all amounts due within thirty (30) days.

14. Third-Party Liability Injuries. If you receive treatment as a result of a third-party liability injury (for example: motor vehicle accidents, premises liability, or other general liability claims against third

parties), the balance for services rendered is considered due in full at the time of the service. Because Endocrinology Associates does not protect charges incurred relating to or arising out of third party liability, we will not accept a delay in payment due to settlement disputes and/or litigation. We will not accept a letter of protection from an attorney as a guarantee of payment or assignment of third party insurance payments. Endocrinology Associates cannot act as administrator to resolve financial arrangements. We may agree to bill a third party insurance company of an at-fault party involved in an accident as a courtesy to you. To bill your claim directly, you must provide us all necessary information to confirm coverage for these payments with the auto/third-party carrier. We will also collect information about your personal medical insurance in case the auto/third-party carrier denies your claim. Regardless of whether we submit your claim to third-party insurance, as the patient, you are ultimately responsible for payment.

15. Ancillary Services. You may receive ancillary medical services while a patient of Endocrinology Associates such as: interpretation of tests, laboratory testing, imaging services (e.g., x-rays, MRIs) and pathology specimen examination. By signing below, you understand that some physicians may not provide services in your presence, but are actively involved in the course of diagnosis and treatment. You authorize payment directly for these services under the policy(s) or plan(s) issued to you by your insurance carrier. You may incur additional charges as a result of these ancillary services. You agree to pay all charges due with respect to such services after benefits paid on your behalf by any third-party are credited to your account.

16. Additional Charges. Patients may incur and are responsible for the payment of additional charges at the discretion of Endocrinology Associates including but not limited to: (i) charges for returned checks; (ii) charges for a missed appointment without 24 hours advance notice; (iii) charges for extensive phone consultations and/or after-hours phone calls requiring treatment, or prescriptions; (iv) charges for copying and distribution of patient medical records; (v) charges for extensive forms preparation or completion; or (vi) any costs associated with collection of patient balances, all as allowed by law.

17. Non-Payment on Account. Should collection proceedings or other legal action become necessary to collect an overdue or delinquent account, you understand that Endocrinology Associates has the right to disclose to an outside collection agency or attorney all relevant personal and account information necessary to collect payment for services rendered. You are responsible for all costs of collection including, but not limited to: (i) late fees and charges and interest due as a result of such delinquency; (ii) all court costs and fees (but only to the extent allowed by law); and (iii) a collection fee to be charged under separate agreement with a third-party collections agency, either as a flat fee or computed as a percentage of the total balance due up to the maximum allowed by applicable law, and to be added to the outstanding balance due and owing at the time of the referral to the third party collection agency. You acknowledge that any such interest assessed on the account will be a late fee as a result of default or delinquency on your account, and is not deemed interest p a r t of a credit transaction. If your account is referred to a collection agency, attorney, court, or the past due status is reported to a credit reporting agency, it may have an adverse effect on your credit history; and related portions of your account, including the fact that you received treatment at our offices, may become a matter of public record. Failure to comply with any of these policies may also result in a Credit Withdrawal of Care.

18. Minor Patients. The parent/guardian of a minor is responsible for payment of the minor’s account balance. A minor who is not accompanied by a parent/guardian will be denied any non- emergency treatment unless charges for the treatment have been pre-authorized. Responsibility for payment of treatment of minor children, whose parents are divorced, rests with both parents. Any court-ordered responsibility judgment must be determined between the individuals involved, without the inclusion of Endocrinology Associates.

19. Authorization to Contact. You authorize Endocrinology Associates personnel to communicate by mail, answering machine messages, and/or e-mail according to the information provided in your patient registration information. Endocrinology Associates , or any agent or servicer of your patient account, may use any information you have provided, including contact information, e-mail addresses, cell phone numbers, and landline numbers, to contact you for purposes related to your account, including debt collection. You authorize Endocrinology Associates to use this information in any manner consistent with the information you have provided, including mail, telephone calls, e-mails, or text messages. You expressly consent to any such contact being made by the most efficient technology available, including automatic dialing/e-mailing or similar equipment, or pre-recorded or other messages, even if you are charged for the contact.

20. Financially Responsible Party. If this or a separate Endocrinology Associates Financial Responsibility Statement is signed by another person, on your account, then that co-signature remains in effect until cancelled in writing. Cancellation in writing shall become effective the date after receipt, and shall apply only to those services and charges thereafter incurred. By signing as a financially responsible party, you hereby guarantee the full and prompt payment to Endocrinology Associates of all indebtedness of patient to Endocrinology Associates , whether now existing or hereafter created (the “Indebtedness”); and you further agree to pay all expenses, legal or otherwise, incurred by Endocrinology Associates in collecting the Indebtedness, in enforcing this guaranty, or in protecting its rights under this guaranty or under any other document evidencing or securing any of the Indebtedness. This guaranty shall be a continuing, absolute and unconditional guaranty, and shall remain in force and effect until any and all said Indebtedness shall be fully paid. There shall be no obligation on the part of Endocrinology Associates at any time to first exhaust its remedies against Patient, any other party, or any other rights before enforcing the obligations of the financially responsible party. _______________________________ Patient Name (Please Print) _____________________________ ____________ Patient Signature Date

Notice of Privacy (HIPAA) Endocrinology Associates P.A. originates and maintains health records, describing your health history, symptoms, examinations, test result, diagnosis, treatments, and any plans for further care. This information serves a basis for your care and treatment, as a means of communication among healthcare professionals who contribute to your care, a source of information for applying your diagnosis and surgical information to your bill, a means by which third-party can verify that services billed were actually provided, and a tool for routine healthcare operations, such as assessing quality and reviewing the competence of healthcare professionals. Your health records may be disclosed by fax, mail, verbal conveyance, type written, and or electronically transmitted to other healthcare professionals to assist in your care. Examples of information that may be in your chart, but that are not considered private according to the Health Insurance and Portability Act ( HIPPA )are: date of birth, address, admission/discharge dates, telephone numbers, and social security number. You have the right to ask your physician, directly, for your health information contained in your medical chart. Family and friends may only have access to your health information if you designate them on the Notice of Privacy Practices form. Information I hereby agree that the enrollment information is correct and I also agree that any changes to the enrollment information will be communicated to Endocrinology Associates P.A. as required to fulfill the medical and financial obligation for services rendered. Authorization I hereby request and consent that my medical records and non-written records be sent to my referring physicians, those physicians or ancillary facilities that I am referred to by Endocrinology Associates P.A. and to my insurance company or its agents that may be authorizing treatment. I further understand that my medical records may contain sensitive information and hereby authorize the release of all confidential HIV related information, communicable diseases related information, drug and alcohol abuse/treatment information and mental health diagnosis/treatment information to the undersigned. _______________________________ Patient name (Please Print) __________________________ Patient Signature

ENDOCRINOLOGY ASSOCIATES9328 East Raintree Drive | Scottsdale, AZ 85260 | (602) 266-8463 | Fax: (602) 266-0122

TRANSFERS FROM ENDOCRINOLOGY ASSOCIATESI hereby authorize Endocrinology Associates to release medical information contained in my medical records to:

(NAME OF PERSON TO RECEIVE INFORMATION)

Address

I hereby authorize:

TRANSFERS TO ENDOCRINOLOGY ASSOCIATES

(NAME OF PERSON TO SEND INFORMATION)

Address Telephone / Fax Number

to release all medical information in my files to:

Dr.

for the purpose of:

AUTHORIZED SIGNATUREI recognize that the information disclosed may contain information that is privileged and protected by law and I specifically consent to disclosure of such information. When expedient, I authorize the transmittal of records by FAX, if my records are FAXED, I relieve the doctors of Endocrinology Associates, P.A. of responsibility for any mistransmission and/or potential breach of confidentiality. I understand that transmission is being sent by a secured fax.

PATIENT NAME (PRINT)

CURRENT ADDRESS

BIRTH DATE

PATIENT SIGNATURE WITNESS/PARENT/GUARDIAN SIGNATUREDate

THIS REQUEST EXPIRES 90 DAYS FROM ABOVE DATE.

Please send copies of the following:

History

Operative report/type operation

X-rays: Type

Medications/Therapy

Lab/path/EKG reports

Other

Date taken Reports

Print Form

Telephone / Fax Number

AUTHORIZATION AND CONSENT TO PARTICIPATE IN TELEMEDICINE APPOINTMENT

The purpose of this form is to obtain your consent to participate in a telemedicine appointment with the following practice: Endocrinology Associates.

1) Purpose and Benefits. The purpose of this is to enable patients to be seen by our providers during the COVID 19 national health emergency.

2) Nature of Telemedicine Consultation: During the telemedicine appointment:

Details of your medical history, examinations, radiology, and blood tests will be reviewed and discussed with you.

3) Medical Information and Records. All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine appointment.

4) Confidentiality. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks

associated with the telemedicine appointment.

5) Risks and Consequences. The telemedicine appointment will be similar to a routine medical office visit, except interactive video technology will allow you to communicate with a physician at a distance. The use of video technology to deliver healthcare is a new service which may not be equivalent to direct patient to physician contact.

6) Rights. You may withhold or withdraw consent to the telemedicine appointment at any time without affecting your

right of future care or treatment.

7) Financial Agreement. This telemedicine appointment will be billed to your insurance carrier.

I have been advised of all the potential risks, consequences and benefits of telemedicine. I understand the written information provided above.

Signature: Patient (or person authorized to give consent)

Date:

If signed by person other than patient, provide relationship to patient:

Witness: Date: