Welcome Letter

Authorization for Treatment / Release of Information

Consent to Treatment: The patient and/or authorized representative d hereby consent to any and all
treatments which may deem advisable by the physician or Tri County Health LLC., Inc. Patient consent to Rx
verification Electronic Data Health Exchange (eEHX Interoperability). Each procedure and diagnostic study will
be discussed in detail with patient before procedure is performed. Additional consent will be required at the
time of procedure.

Assignment of Insurance Benefits: I assign payment directly to Tri County Health LLC, Inc. Insurance
Benefits otherwise payable to me, I understand that I am financially responsible got charges paid by this
assignment. I will assist in the collection of my insurance payment got any claims unpaid after 30 days. If after
45 days the claim remains unpaid, I understand the balance will be due from me.

Medicare Patients: I certify that the information given by me in applying for payment under the XVIII
of the Social Security is correct. I authorize Tri County Health LLC, to release to the Health Care Financing
Administration of its intermediaries any information needed for this related Medicare claim, I hereby
authorize payment directly to Tri County Health LLC., Inc for medical benefits otherwise payable to me as
beneficiary of the Medicare Program and such other payments as may be due by other third party payers. I
agree to execute such documents as may be necessary to apply for and obtain payment. I understand that
such services as, but not limited to routine testing may be covered by Medicare unless the physician provides
medical necessity.

Patient/ Guarantor Agreement: I understand that Tri County Health LLC, is not in business expanding
credit. Therefore, it is the policy of Tri County Health LLC. To require payment in full at the time of service. If
unable to pay due balance in full at the time of service, I agree to make prior arrangements with the Billing
Department.

I understand that I am financially responsible for my/ the patient’s account with Tri County Health LLC.
Regardless of my insurance benefits, I authorize copies of this form to be valid as the original.

Patient Consent for Use and Disclosure of Protected Health Information

I hereby give my consent for Tri County Health LLC to use ad disclose PHI about me to carry out
treatment, payment and health care operations (TPO).

I have the right to review the Notice of Privacy Practices prior to signing this consent. Tri County Health
LLC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices
may be obtained by forwarding a written request to Tri County Health LLC.

With this consent, Tri County Health LLC may call y home or other alternative location and leave a
message o voice mail or e-mail/text me, publish my records to patient portal in reference to any items that
assist the practice in carrying out TPO. This may include appointment reminders, insurance issued, and
concerns with my clinical care, such as laboratory test results, diagnostic imaging, Integrated Data records
Exchange (eEHX), Marketing, etc.

With this consent, Tri County Health LLC, may mail to my home or other alternative location any items
that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements if
they are marked “Personal and Confidential”.

With this consent, Tri County Health LLC, may text or e-mail to my home or alternative location, any
items that assist the practice in carrying out TPO, such as appointment reminders, patient statements, and
medical records. I have the right to request that Tri County Health LLC restrict how it uses or discloses my PHI
to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound
by this agreement.

By agreeing to this form, I am consenting to allow Tri County Health LLC to use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures
based upon my prior consent. If I do not sign this consent, or later revoke it, Tri County Health LLC, may
decline to provide treatment to me.