Physician Disclosure

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1 Physician Disclosure As required by Section of the Texas Occupations Code, a physician must disclose to a patient those arrangements permitted under applicable Texas law whereby such physician accepts remuneration to secure or solicit a patient or patronage for a person licensed, certified or registered by a Texas health care regulatory agency. The purpose of this Disclosure is to notify you, the patient, that Dr. Michael Ellman may receive remuneration in connection with p] referring you to Rx Unlimited Compounding Pharmacy for certain compounded pharmacy products, and pi) assisting such pharmacy in developing, implementing, and monitoring evidence-based best practice standards and pain management protocols with respect to the safe and effective use of compounded pharmacy products. I acknowledge that my attending physician(s).have disclosed to me, at the time of initial contact and at the time of referral p}his affiliation, if any, facilities or entities for whom, I, the patient am being referred, and (ii) that he will receive, directly or indirectly, remuneration for the referral to facility entity. I understand that I, the patient, have the right to choose the providers of my health care services. You have the right to choose the provider of your healthcare services. Therefore, you have the option to use a healthcare facility, laboratory, or pharmacy other than those listed. You will not be treated differently if you choose to obtain healthcare services by any other facility than those listed. In addition, I understand that Dr. Michael Ellman has ownership interest in the following facilities: Presbyterian Hospital of Rockwall, Legacy Laboratory Services LLC, Preferred Imaging on Piano Parkway, Bent Tree Pain Procedure Center LLC, APSP-North Central LLC If you have any questions or concerns regarding this notice, feel free to ask Dr. Ellman or any representative of the listed facilities. We welcome you as a valued patient and value our relationship with you. By signing this Disclosure of Physician Ownership, you acknowledge that you have read and understand the foregoing notice and understand that your physician has an ownership interest in above mentioned facilities. Signature of Patient Date Print Name of Patient

2 Pain Management Non-operative Spine Care EMG/NCS. Sports Medicine Male: Female First Middle Last Street City State Zip HomePh: C ell Ph: SSN: - - Birth Marital Status: Y N Spouse: Drivers Lie: Ht: Wt: Refferinq Dr/Attorney: Phone #: Street City State Zip Emergency Contacts Name: Ph: Relationship:. Insurance Information: Please present card and drivers license to receptionist Primary lnsurance:_ Group #:_ Secondary Insurance: Group#:_ ID#: policy Holder^ ID#: _Policy Holder:_ 2692 N. Galloway Suite 402 Mesquite, Texas Phone Fax

3 Pain Management Non-operative Spine Care EMG/NCS Sports Medicine Patient Consent Form I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and willbe used to: # Conduct, plan and direct my treatment and follow-up among the multiple Healthcare Providers who may be involved in the treatment directly and indirectly. *> Obtain payment from third party payers. * Conduct normal healthcare operations such as quality assessments and physician certifications. I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. Print _ Signature: 2692 N. Galloway Suite Mesquite, Texas Phone Fax

4 AM lehab ASSOCIATES Pain Management Non-operative Spine Care EMG/NCS Sports Medicine Financial Policy First Middle Last Please initial each line * ; *Our office is not responsible for determining if we are on your insurance plan. It is your responsibility to contact your insurance plan for this information. _*lnsurance companies require that copayments are due at the time of service. * f you do not have insurance or if you have a deductible that has not been met, payment in full is expected at the time services are rendered. *You must present your insurance card and driver's license at the time of each visit. If you are unable to produce proof of eligibility, payment in full will be expected at the tim.e services are rendered. * f our office is not notified of insurance changes within SOdays of the date of service, the account holder will be expected to pay in full for all charges for that date of service. *Claims for any services not covered or considered not a benefit by insurance companies will be billed to the responsible party. : *We accept cash, personal checks, Visa & Mastercard., *We reserve the right to charge $25 for missed appointments. Insurance companies do not pay this fee. It is your responsibility to pay this charge. Please call the office at ieast 24 hours in advance if you need to cancel or reschedule your appointment, so that we can offer the appointment to another patient. *We charge $50 if we forward your account to a collection company. j*you agree, in order for us to service out account or to collect any amounts you may owe, we may contact you by telephone at the telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact by sending text messages or s, using any address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and /or use of an automatic dialing services, as applicable. I/We have read this disclosure and agree that the creditor may contact rne/us as described above. ; _ * have read and agree to the financial polices of Ellman Rehab Associates/Regenerative Ortho Spine of Texas. I assign insurance benefits to be paid directly to Ellman Rehab Associates/and or Regenerative Ortho Spine of Texas. I authorize the release of medical information on my behalf to insurance companies for the purpose of filing insurance claims. ' Signature of Patient: j _ 2692 N. Galloway - Suite 402 Mesquite, Texas Phone Fax

5 XJiJ Pain Management. Non-operative Spi.ne Care - EMG/NCS Sports Medicine Request For Release of Medical Records First Middle Last Patient Date of Birth: I hereby request and authorize the following provider to release medical records for the following patient. Provider Name: City, State & Zip:. Office Ph: Fax: Please release all medical records from (date) to Please Forward Records To: Ellman Rehab Associates 2692 N. Galloway Suite 402 Mesquite, TX Ph: Fax: N. Galloway. Suite 402 Mesquite, Texas Phone Fax

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