NEW PATIENTINFORMATION INSURANCE INFORMATION PLEASE PROVIDE OUR OFFICE WITH A COPY OF YOUR INSURANCE CARD EMERGENCY CONTACT THIRD PARTY BILLING

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1 NEW PATIENTINFORMATION Patient : of Birth: Address: City: State: Zip: SSN: Phone #: Work #: INSURANCE INFORMATION PLEASE PROVIDE OUR OFFICE WITH A COPY OF YOUR INSURANCE CARD Primary Insurance: of Insured: SSN: Relationship to Patient Group #: Member #: Insured s Employer: Phone #: Secondary Insurance: of Insured: SSN: Relationship to Patient Group #: Member #: Insured s Employer: Phone #: If the patient is a minor, please list both parent s names and employer Mother Employer Phone #: Father Employer Phone #: EMERGENCY CONTACT : Phone #: THIRD PARTY BILLING Is your injury work related? Yes No Is this injury due to an accident? Yes No If your injury is MVA related, have you obtained an accident report? Yes No of Injury or Accident: Surgery : Which part of the body are you being seen for? Right Left Both Who referred you to DuraTech Medical, Inc.?

2 I am in need of a prosthesis and hereby consent to DuraTech Medical, Inc. providing the care and services attendant to my orthotic needs. I understand that the inappropriate use of a prosthesis could involve possible bodily risks or injury. I acknowledge that no guarantees have been made to me as to my ability to use my prosthesis once fitting is complete. Waiver and Release for Non-Orthotic Care I further understand that DuraTech Medical, Inc. s sole business is to fit my prosthesis. Prior to coming to DuraTech Medical, Inc., I have been instructed on safe transfer techniques. If at any time during my prosthesis fitting I need assistance to transfer from chair, wheelchair, table or commode, I hereby release DuraTech Medical, Inc., its directors, officers and staff from any liability associated with any injury I incur during any such transfer whether assisted or not. Assignment of Benefits As a courtesy to patients and their families, DuraTech Medical, Inc. does submit a claim to many third party payers. I request that payment of authorized Medicare or private benefits be made to DuraTech Medical, Inc. for any covered services furnished to me by DuraTech Medical, Inc.. If my insurance carrier pays me directly, I agree to forward all funds to DuraTech Medical, Inc. within ten (10) working days. I agree that I am responsible for paying all non-covered or unpaid amounts unless otherwise provide by law, regulation or DuraTech Medical, Inc. contractual relationships. I agree to be responsible for the full amount of the charges from the date of delivery which my third party payer does not pay for in a timely manner, or if my physician or I fail to provide within ten (10) days the information necessary to submit the claim for payment. Disclosure of Information I understand that my medical records and billing information are made and retained by DuraTech Medical, Inc. and are accessible to DuraTech Medical, Inc. personnel, who may use and disclose medical information for DuraTech Medical, Inc. operations and functions and to any other health care personnel involved in my continuum of care for this admission. Release of Records I authorize DuraTech Medical, Inc. to release to any governmental health care program and its agents, or to any private insurance company or its agents any information needed to determine my benefits or the benefits payable for DuraTech Medical, Inc. services. I hereby authorize my attending physician to release all medical records pertaining to my prosthesis to DuraTech Medical, Inc.. I UNDERSTAND THE INFORMATION AUTHORIZED FOR RELEASE MAY INCLUDE RECORDS DOCUMENTING THE PRESENCE OF A COMMUNICABLE OR VENEREAL DISEASE WHICH MAY INCLUDE, BUT IS NOT LIMITED TO, DISEASES SUCH AS HEPATITIS, SYPHILIS, GONORRHEA AND THE HUMAN IMMUNODEFICIENCY VIRUS ( HIV ) ALSO KNOWN AS ACQUIRED IMMUNE DEFICIENCY SYNDROME ( AIDS ). Acknowledgement of NOTICE OF PRIVACY PRACTICES A complete description of how my medical information will be used and disclosed by DuraTech Medical, Inc. has been given to me in DuraTech Medical, Inc. s NOTICE OF PRIVACY PRACTICES. I have been given the opportunity and have been advised to read the notice prior to signing this consent form. I authorize DuraTech Medical, Inc. to take pictures of the fitting of my device that may be used for educational and marketing purposes. Patient (or Parent/Guardian or Representative) Printed Relationship (if not patient) Witness

3 PATIENT MEDICAL HISTORY FORM Patient s : Age: Height: Weight: Please check all conditions for which you have been or are being treated: Diabetes Type 1 Type 2 Treating physician: Poor circulation Edema Where: Neuropathy Where: Allergies List: Skin problems Where: Are you able to walk unassisted? Yes No Do you use assistive devices? Yes No If yes, what device(s)? Have you ever worn any type of brace? Yes No When? If yes, was it worn on your knee hip back foot ankle If you currently reside in a nursing home or assisted living facility, please indicate the name and location: Location With whom are we authorized to discuss your patient information? Relationship Relationship Signature

4 MEDICARE DMEPOS SUPPLIER STANDARDS Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R (c). 1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements. 2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days. 3. An authorized individual (one whose signature is binding) must sign the application for billing privileges. 4. A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs. 5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment. 6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty. 7. A supplier must maintain a physical facility on an appropriate site. This standard requires that the location is accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records. 8. A supplier must permit CMS, or its agents to conduct on-site inspections to ascertain the supplier s compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation. 9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine or cell phone is prohibited. 10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations. 11. A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from calling beneficiaries in order to solicit new business. 12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery. 13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts. 14. A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries. 15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries. 16. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicarecovered item. 17. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier. 18. A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number. 19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility. 20. Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it. 21. A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations. 22. All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals). 23. All suppliers must notify their accreditation organization when a new DMEPOS location is opened. 24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare. 25. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation. 26. Must meet the surety bond requirements specified in 42 C.F.R (c). 27. A supplier must obtain oxygen from a state-licensed oxygen supplier. 28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R (f). 29. DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers. 30. DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions. Disclosure Accounting: You have the right to receive a list of disclosures we have made of your medical information for the last 6 years, but not before April 14, If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Restriction: You have the right to request a restriction or limitation on the protected medical information we use or disclose about you for treatment, payment or health care operations. However, we must receive your restrictions in writing before we have made such disclosures. You also have the right to request a limit on the protected medical information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. We are not required to agree to your request. If we do agree, we will abide by our agreement (except in an emergency). Complaints: If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services. To file a complaint with our office, please submit it in writing to the address as follows: PRIVACY OFFICER 5204 Tennyson Parkway Suite 100 Plano, Texas Phone: (214) We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us, with the U.S. Department of Health and Human Services (Medicare) at MEDICARE ( ) or our accrediting organization, The Board of Certification/Accreditation, International at HIPAA PATIENT PRIVACY NOTICE DME SUPPLIER This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your health information is important to us. OUR LEGAL DUTY We are required by applicable Federal and State law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. This notice takes effect April 14, We reserve the right to change the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for health information that we maintain, including health information we created or received before we made the changes. USES AND DISCLOSURES OF HEALTH INFORMATION The following categories describe different ways that we use and disclose protected medical information. Treatment: We may use and disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. National Security: We may release protected medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. We may disclose to law enforcement officials having lawful custody of a patient the protected health information of the patient under certain circumstances mandated by law. Workers Compensation: We may release protected medical information about you for workers compensation or similar programs. These programs provide benefits for work-related injuries or illness. Release of such information is controlled by State and/or Federal law. Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose protected medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. PATIENT RIGHTS Access: You have the right to inspect and copy medical information that may be used to make decisions about your care. This includes medical and billing records. To inspect and/or copy your medical information you must submit your request in writing. You will be charged $.25 per page for copies, plus our postage costs. Right to Amend: You have the right to request that we amend your health information. Your request must be in writing and you must provide a reason that supports your amendment request. We may deny your request if you ask us to amend information that: was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the medical information kept by our practice; in our judgment is accurate and complete as it appears or as it was at the time it was originally captured and recorded. PRODUCT WARRANTY The warranty period for custom orthoses is three (3) months for workmanship and materials. Although DME Supplier cannot be responsible for physiological or anatomical changes in the patients medical condition, DME Supplier will attempt to maintain proper fit during this period. Normal adjustments to enhance fit will be made at the discretion of the practitioner at no charge for a period of up to one (1) year. Additions of components, straps, lifts, etc. prescribed by a physician will incur a charge. There will be a separate charge for adjustments or repairs that are made as a result of abuse or tough wear, as may occur from sporting, vocational or unusual activities. Since orthoses are prescribed at the direction of a physician, and custom fabricated for the anatomy and medical condition of each individual client, they cannot be returned for credit or refund. Prescribed off-the-shelf items cannot be returned for hygienic reasons. Off-the-shelf braces will be warranted as the manufacture warranties apply. See below for examples: Post-Operative Brace 180 days mechanical functionality/components Walking Boots 180 days mechanical functionality/components Functional Braces OTS Knee 1 year hinge functionality/components 5 years against shell breakage Custom Braces Knee 1 year hinge functionality/components Lifetime against shell breakage Osteoarthritic Braces (OTS and Custom) 3 years hinge functionality/components Please communicate any problems or discomfort you are experiencing to your practitioner immediately to allow us to resolve problems as efficiently and quickly as possible. 30,240.1, 09/12

5 PROOF OF DELIVERY AND SATISFACTION Patient : Detailed Description of Item Received: Quantity Received: Received: Brand (if applicable): Serial Number (if applicable): This is to certify that I have received the above listed item or service. I am satisfied with both the workmanship and fit of my device and I have been fully advised as to the care, use and donning of the device(s). This is to certify that I have been advised of the warranty coverage on the product I received today. Patient Signature: 30,240.1, 09/12