SaVida is committed to providing you with the highest level of patient care. Charges for services in our practice are within

the “usual and customary” rates for our area. All professional services rendered are charged to the patient or financially

responsible party. As a courtesy to you, SaVida will file all claims to your insurance company. All services rendered must be

paid in full at the time of service, until your deductible has been satisfied. If you do not have a deductible, or it has been

met, you must pay all “co-payments” or percentages as dictated by your insurance carrier. If you have met your deductible

with another provider, documentation must be provided. If you do not have insurance, you must pay in full at the time of

service, unless prior arrangements have been made (financial plans are available). Your insurance policy is a contract

between you and your insurance company. If your insurance company has not paid your account in full within 90 days, you

will be responsible for the remaining charges. We will continue to assist you in resolving any outstanding balance. I

understand and agree that I am solely responsible for all charges to my account. I agree to pay all collection costs,

returned check fees, attorney fees and court costs incurred by SaVida Health and/or Agency in the collection of all charges

due.

I understand that the confidentiality of all medical records will be protected to the full extent of the law. I authorize SaVida

Health and/or Agency to release all information (electronic or otherwise) from my medical record and/or billing

information to:

a. Any person or entity responsible for payment for the medical services rendered to me at SaVida, including third

party payors, organizations, insurance companies, self-insurers, worker's compensation carriers and government

agencies, or any person or entity acting as the agent or contractor of such party responsible for payment, in

connection with obtaining payment for the medical services rendered to me by employees of SaVida Health

and/or Agency or any person providing services at SaVida.

b. Federal, State or other governmental or quasi-governmental agencies or such other parties required by law for

reporting purposes or for purposes of determining eligibility in government sponsored benefit programs.

c. Any person, auditor, or entity participating in quality studies, utilization review (clinical or financial) or similar

studies of the care rendered by SaVida and/or its physicians and providers.

d. Any health professionals involved in my care for the purpose of facilitating the continuity of my medical care.

e. Persons authorized by SaVida to conduct supervised research in compliance with the rules and procedures of

SaVida.

SaVida Health and/or Agency provides information about how protected health information about me (the patient)

including information about human immunodeficiency virus (HIV), AIDS related complex (ARC); and acquired

immunodeficiency syndrome (AIDS); and including substance abuse treatment records protected under the regulations in

42 Code of Federal Regulations, Part 2, if any; and psychological and social services records, including communications

made by me to a social worker or psychologist (if any) may be used and disclosed. I have been offered an opportunity to

review the Notice before signing this form.

I understand that the terms of this agreement may change and that I may obtain a revised copy by accessing SaVida

Health and/or Agency’s website at www.savidahealth.com. I understand that I have the right to request restrictions on

how my protected health information is used or disclosed for treatment, payment or health care operations. My providers

are not required to agree to this restriction, but if they agree, they will be bound by the agreement.