I/We do hereby consent to and authorize the performance of all treatments, surgeries and medical services deemed advisable by the physicians and the staff of the Pravinchandra P Patel MD PC to me or to the above-named minor of whom I am the parent or legal guardian. I hereby certify that, to the best of my knowledge, all statements contained hereon are true. I understand that I am directly responsible for all charges incurred for medical services for myself and my dependents regardless of insurance coverage, excluding only authorized services provided under a valid prepaid HMO contract. I furthermore agree to pay legal interest, collection expenses, and attorneys' fees incurred to collect any amount I may owe. I also hereby authorize Pravinchandra P Patel MD PC to release information requested by insurance company and/or its representatives. I fully understand this agreement and consent will continue until cancelled by me in writing.

1) Assignment and Coordination of Insurance Benefits - I agree to provide information regarding all group hospitalization, health maintenance organization, Workers' Compensation, automobile, and other health care benefits ("Insurance Plan(s)") to which I may be entitled. I hereby assign payment(s), if any, from my Insurance Plan(s) to PRAVINCHANDRA P PATEL MD PC (or its affiliate) and each of the independent contractor physicians and/or professional corporations for services rendered to me. The direct payment hereby assigned and authorized includes any Insurance Plan(s) benefits to which I am otherwise entitled, including any major medical benefits otherwise payable to me under the terms of my policy, but is not to exceed the balance due to PRAVINCHANDRA P PATEL MD PC (or its affiliate), the independent contractor physicians and/or professional corporations for services rendered to me during the applicable periods of medical care.

2) Unauthorized, Non-Covered, or Out of Plan Services - I understand if my Insurance Plan(s) does not consider this admission or any service rendered during this admission a covered service or has not authorized this service, they will not pay for this admission or the service rendered during this admission or outpatient visit. I agree to be fully responsible for payment to PRAVINCHANDRA P PATEL MD PC for this admission or any service if determined by my Insurance Plan(s) to be a non-covered service. I also understand and acknowledge that in the case of Out of Plan/Network services, there may be reduced benefits and I may be required to pay a larger co-payment, co-insurance or other charge in the event my Insurance Plan(s) does not reimburse these services provided to me, I acknowledge I will be responsible for any remaining balance.

3) For Medicare Recipients Only - I certify the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I request that payment of authorized Medicare benefits be made on my behalf to the Hospital and/or independent contractors for any services furnished to me by that physician or supplier. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for the related services. In the case of Medicare Part B benefits, I request payment either to myself or to the party who accepts assignment.

4) Residents, Interns or Medical Students- I understand residents, interns, medical students and other health care professional students may participate, under the supervision of an attending physician or other health care professional, in my care as part of the Inova Health System's education programs.

By signing below, I certify I have read and understand the foregoing, have had the opportunity to ask questions and have them answered and accept the above conditions and terms and I agree to pay all charges for which I may be legally responsible including, but not limited to health insurance deductibles, co-payments, and non-covered. I also agree in the event my account must be placed with an attorney or collection agency to obtain payment, I will pay the reasonable attorneys' fees and other collection costs incurred by PRAVINCHANDRA P PATEL MD PC. /understand and agree this document will remain in effect for all future outpatient or physician office visits to PRAVINCHANDRA P PATEL MD PC, unless specifically rescinded in writing by me.

I certify that I have been made aware of Inova Health System's Notice of Privacy Practices and that I have a right to receive a copy upon request. This Notice describes the type of uses and disclosures of my protected health information that might occur during my treatment, to facilitate the payment of my bills or in the performance of PRAVINCHANDRA P PATEL MD PC's health care operations. The Notice also describes my rights and PRAVINCHANDRA P PATEL MD PC's duties with respect to my protected health information. I understand that copies of the Notice of Privacy Practices are available in the registration areas of each facility and on PRAVINCHANDRA P PATEL MD PC's web site at www.patelfamilymedical.com. I may request that a copy be mailed to me by calling 662-622-7011.

PRAVINCHANDRA P PATEL MD PC 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 above number and requesting a revised copy be mailed to me, by asking for one at the time of my next appointment, or by accessing PRAVINCHANDRA P PATEL MD PC's web site listed above to view the most current version.

Whenever you are seen in our office, whether it be a scheduled appointment or as a walk-in, it is your responsibility to inform us if you have been or will be seen at another provider's office on the same day of seeing one of our providers. If you fail to inform us of this and your insurance company does not pay for your treatment at our office, then payment for that office visit and treatment received for that day will become your responsibility.

I have read the financial policies contained above, and my signature below serves as acknowledgement of a clear understanding of my financial responsibility. I understand that if my insurance company denies coverage and/or payment for services provided to me, I assume financial responsibility and will pay all such charges in full.