Thank you for choosing Epic Care for your medical needs. We are committed to providing you with the highest quality healthcare. Please read and sign this form to acknowledge your understanding of our Terms and Conditions of Service.

1. MEDICAL CONSENT

I, the undersigned patient or legal guardian, consent to the general treatment and procedures that may be performed. These procedures may include but are not limited to laboratory procedures, x-ray examinations, medical or surgical treatments or procedures provided to the patient under the general and special instructions of the patient's physician or surgeon. I understand that it is the responsibility of the patient's physician to obtain the patient's informed consent when required when required for specific medical or surgical treatment and special diagnostic or therapeutic procedures. I understand and agree that at the request of the attending physician, health practitioners (such as physician assistant and nurse practitioners) may participate in the patient's care.

2. FINANCIAL AGREEMENT

For the service(s) to be rendered, I agree to accept full financial responsibility for the patient's account in accordance with the regular rules and terms of Epic Care. This includes financial responsibility for all deductibles and co-payments that may be required by the patient's insurance. This also includes services or supplies not covered by the patient's insurance and or Medicare. There is also a $25 service fee for returned checks and a $50 no show fee. Should the patient's account(s) be referred to a collection agency or an attorney, I further agree to pay actual attorney's fees incurred in addition to other amounts due. When the service(s) to be billed to insurance, a health plan or another payment source, paragraphs 3 (Contracted Health Plan Patients and other Sources) and 5 (Assignment of Insurance Benefits) will also apply.

3. CONTRACTED HEALTH PLANS PATIENTS AND OTHER SOURCES

I understand that the patient may be eligible for certain health care coverage through a health plan (HMO, PPO) on the list of health plans with which Epic Care contracts, or through some other source (e.g., clinical trial sponsor, employer's workers' compensation insurance I agree to be responsible under paragraph 2 (Financial Agreement) for paying the patient's account: (a) if Epic Care does not contract with the health plan; (b) for any co-payments and deductibles; (c) for services not approved by the health plan or other source (d) for services not covered and/or paid for by the patient's health plan or other source to the extent allowed by law or contract.

4. ASSIGNMENT OF INSURANCE BENEFITS (INCLUDING MEDICARE BENEFITS)

I, authorize direct payment to Epic Care of any insurance benefits otherwise payable to or on behalf of the patient for services, at a rate not to exceed the actual charges. I understand and agree that I am financially responsible under paragraph 2 (Financial Agreement) for charges not paid in accordance with this assignment. I hereby give lifetime authorization for payment of insurance benefits to be made directly to Epic Care, and any assisting physicians, for services rendered.

The undersigned certified that he/she has read the Terms and Conditions of Service, has received a copy of it, and is the patient or a duly authorized by or on behalf of the patient to execute and accept its terms.