DIABETES & ENDOCRINE WELLNESS CENTER, LLC

1 Hospital Drive SW, Suite 300 Huntsville, AL 35801

Phone: 256-881-2700 Fax: 256-429-9109

We are dedicated to providing the best possible care for you, and we want you to completely understand our practice policies.

1. Payment is due at the time of service. We accept, Cash, Discover, MasterCard, and Visa. If you are not able to pay your co-pay at the time of your visit, we will ask that you reschedule your appointment until you are

2. The patient is responsible for all incurred charges. We will file a claim with your insurance company as a courtesy; however it is the patient's responsibility to provide us with accurate and complete insurance information by presenting their insurance card at the time of each visit. Failure to do so will result in the patient incurring the total expense for their care. 3. Your insurance policy is a contract between you and your insurance company. As a service to you, we will file your insurance claim if you assign the benefits to the doctor. This means that you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will contact you for payment. Any overpayment subsequently made by your insurer will be refunded to you. 4. We have made prior arrangements with many insurance companies and other health plans to accept an assignment of benefits. We will bill them, and you are required to pay a copayment at the time of your visit. If you are insured by a plan with which we do not have a prior arrangement, we will prepare and send the claim for you on an unassigned basis. This means the insurer will send the payment directly to you. Therefore, our charges for your care are due at the time of service. 5. Not all insurance plans cover all services. In the event your insurance plan determines a service to be "not covered," you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office. The patient is responsible for making sure they know what benefits are included under their insurance plan, as well as making sure they are following all the regulations put forth in the plan benefits provided to them by their insurance company. Any out of network fees assessed by the insurance company will become the responsibility of the patient. 6. Patients are expected to make our office aware of any changes in insurance, mailing address and phone number. 7. Any unpaid balance is due prior to being seen by our physicians. 8. If there is an outstanding balance existing for more than 90 days, it will be placed with an outside collection agency. The patient will be responsible for any collection fees, costs, and interest and/or attorney fees in addition to the unpaid balance. 9. If required by insurance, patients are required to provide Diabetes and Endocrine Wellness Center, LLC with a valid referral from their PCP prior to their visit. If a referral is not obtained by the patient or provided by the PCP prior to the patient's visit, the appointment will be rescheduled to another day. 10. There is a fee for forms to be completed by your provider. Forms may take up to 10 days to complete.

Diabetes and Endocrine Wellness Center, LLC Patient Policies (rev: March 2018)

11. Our practice requires a fee for medical records requests. Payment is due prior to the release of any records. Please note that it may take up to 10 business days to process medical record

12. Failure to meet your financial responsibilities may result in one of the following: Discharge from our practice. Patient may be required to make full payment on account before continued treatment. Patient may be required to sign a payment arrangement to resolve any outstanding balance. 13. Any patient that is 15 minutes late for their appointment may be required to reschedule.

Lab/Test Results Lab results may take up to 2 weeks. If you use a LabCorp or Quest facility, once your labs are reviewed by your provider, you may access those lab results online through your patient portal by logging into our website at

www.dewcenter.com. If you elected to provide our office with an email address, your patient portal should be

Prescription Refill Policy Prescriptions refills in between visits are provided for a charge. The process may take up to 72 hours and require that you have been seen by one of our providers in the past twelve months. You may request a refill & pay through your patient portal. No Show Policy If you cannot keep an appointment, please notify our office at least 24 hours prior to visit. Failure to do so will result in a $50 No Show Fee. Patients who do not show up for their scheduled appointment will be responsible for this fee before rescheduling. If you no-show multiple times, you may jeopardize your ability to schedule further appointments in our office. Electronic Prescription History Data Access By signing below I give permission for Diabetes and Endocrine Wellness Center, LLC to access my pharmacy benefits data electronically. This consent will enable Diabetes and Endocrine Wellness Center, LLC to: Determine the pharmacy benefits and drug copays for a patient's health plan. Check whether a prescribed medication is covered (in formulary) under a patient's plan. Display therapeutic alternatives with preference rank (if available) within a drug class for non- formulary medications. Determine if a patient's health plan allows electronic prescribing to Mail Order pharmacies, and if so, e-prescribe to these pharmacies. Download a historic list of all medications prescribed for a patient by any provider.

I have read and understand the practice's policies. I understand that these policies may be amended by the practice from time to time without notice. My electronic signature signifies that I have received the practice's privacy statement, and I hereby agree to be bound by the practice's financial policies. I consent to the performance of examinations, diagnostic procedures and treatments which my physician deems necessary. I also give permission to access my prescription history electronically, take a digital photograph for identification and to

be contacted via phone for miscellaneous reminders from the office. This consent shall remain in effect untilI choose to revoke it in writing.

Diabetes and Endocrine Wellness Center, LLC Patient Policies (rev: March 2018)