Common use of Acceptance of Patients Clause in Contracts

Acceptance of Patients. We reserve the right to accept or decline patients based upon our capability to appropriately handle the patient’s primary care needs. We may decline new patients pursuant to the guidelines proffered in Section 6 (Term), because the Nurse Practitioner’s panel of patients is full (capped at 1,200 patients or fewer), or because the patient requires medical care not within the Nurse Practitioner’s scope of services. Appendix 2 - Itemized Fees Ongoing Primary Care is included with the Periodic Fee described in Appendix 1. Please see a list of some of the chronic conditions we routinely treat on the Practice website (subject to change). There are no itemized fees for office visits. In-Office Procedures we are generally comfortable performing are listed on the Practice website. These are typically available at no additional cost unless otherwise designated, and these are also subject to change. Laboratory Studies will be drawn in the office or lab center at a discounted rate negotiated with the lab. Medications will be ordered in the most cost effective manner possible for the Patient at wholesale cost. Pathology studies (most commonly skin biopsies) will be ordered in the most economical manner possible. Anticipated prices for these studies (subject to change) are discounted at rate negotiated with the lab. Radiology studies will be ordered in rate negotiated with the lab. Surgery and specialist consults will be ordered in the most cost effective manner possible for the Patient. Vaccinations are NOT offered in our office at this time due to the cost prohibitive nature of stocking a limited supply. We will make an effort to help you obtain needed vaccinations elsewhere in the most cost effective manner possible. Hospital Services are NOT covered by our membership plan. If you need to be hospitalized, you will be under the care of a Hospitalist. We will work collaboratively with your Hospitalist and coordinate your care following discharge from the hospital. Signed: Date

Acceptance of Patients. We reserve the right to accept or decline patients based upon our capability to appropriately handle the patient’s primary care needs. We may decline new patients pursuant to the guidelines proffered in Section 6 (Term), because the Nurse PractitionerProvider’s panel of patients is full (capped at 1,200 patients or fewer)full, or because the patient requires medical care not within the Nurse PractitionerProvider’s scope of services. Appendix 2 - Patient Name Patient (Guardian) Signature Date (MMDDYYYY) Direct Primary Care (DPC) Itemized Fees Ongoing Primary Care Care: is included with the Periodic Fee described in Appendix 1. Please see a list of some of the acute and chronic conditions we routinely treat on the Practice website (website. Conditions we treat are subject to change). There are no itemized fees for office visits. In-Office Procedures and Medications: Procedures we are generally comfortable performing are listed on the Practice website. These are typically available at no additional cost included with the Periodic Fee described in Appendix 1 unless otherwise designated, and designated on the website. Procedure fees are is subject to change. Medications may be administered in our office via an injectable or oral route. Patient will be charged our “BEST” price for these medications. Medication fees are also subject to change. Laboratory Studies Studies: We have the capability to draw blood for nearly any test you may need. Most lab specimens will be drawn in processed by an outside facility. A listing of some common laboratory tests and their fees are cited on the office or lab center at a discounted rate negotiated with the labPractice website. Medications will be ordered in the most cost effective manner possible for the Patient at wholesale costThis list is not comprehensive. Laboratory fees are subject to change. Pathology: Pathology studies (most commonly skin biopsiesbiopsies and Paps) will be ordered in the most economical manner possiblepossible and will be sent to an outside facility for analysis. Anticipated prices for these studies (Pathology fees are subject to change. Reflex Testing: Pricing for certain lab and pathology tests dependent on “reflex testing” (when a certain initial result requires additional testing on the same specimen) are discounted will not be known at rate negotiated with the time of specimen submission, therefore, lab/pathology pricing, if cited on the Practice website, indicates the cost for the initial test. The Patient will be charged for reflex testing once it is determined that a reflex test was required and performed on a specimen. Radiology: Radiology studies will be ordered in rate the most cost-effective manner. We do not provide radiology Services on site at this time, therefore, the pricing for such Services is determined by the outside facility performing such Services. Patients will be referred to an outside facility for all radiology procedures. Practice website will be updated with negotiated with the labprices as they become available. Surgery and specialist consults Specialist Consults: Referrals to Surgeons and Specialists will be ordered in the most cost cost-effective manner possible for the Patient. Pricing for all outside specialty referrals is determined by the organization you are being referred to. Vaccinations: Vaccinations are NOT offered in our office at this time due to the cost prohibitive nature of stocking a limited supply. We will make an effort to help you obtain needed vaccinations elsewhere in the most cost cost-effective manner possible. Hospital Services: Hospital Services are NOT covered provided by the Practice, and due to hospital rules and regulations, we have elected NOT to obtain formal hospital admission privileges for direct care at this time. Virtual Visits (Phone Visit and Televideo Visit): Practice may offer televideo and phone virtual visits to Patients. These visits typically are offered to Patients who have a minor condition that can be diagnosed with reasonable certainty without a face-to-face visit and to Patients who have had a recent visit which generated multiple lab abnormalities requiring further Provider consultation. This form of visit is offered by Provider discretion as a convenience to Patients where an office visit would normally be required. Virtual visit fees are included in the Monthly Periodic Fee. Other Services: Practice may add additional Services in the future. These will be posted on our membership planwebsite. If you need Patient Name Patient (Guardian) Signature Date (MMDDYYYY) I, , have received a copy of Priority Medical Partners Direct, SC “Notice of Privacy Practices”. Patient’s Name Signature of Patient Date I authorize Priority Medical Partners Direct, SC to be hospitalized, send email or text which may include unencrypted protected health information. (Providing us with authorization to email and text you will be under allow Priority Medical Partners Direct, SC to exchange information with you more efficiently and will benefit you as a patient. At the same time, we recognize that email and text messaging are not a completely secure means of communication. You are not required to authorize the use of email and text messages and a decision to not authorize electronic communication will not affect your health care of a Hospitalistin any way. We will work collaboratively have taken considerable effort to protect the personal health information of our patients and recommend that all patients provide us with your Hospitalist and coordinate your care following discharge from the hospital. Signed: this authorization so that we can more efficiently communicate with them.) Name of Patient Signature of Patient Date

Acceptance of Patients. We reserve the right to accept or decline patients based upon our capability to appropriately handle the patient’s primary care needs. We may decline new patients pursuant to the guidelines proffered in Section 6 (Term), because the Nurse PractitionerPhysician’s panel of patients is full (capped at 1,200 patients or fewer)full, or because the patient requires medical care not within the Nurse PractitionerPhysician’s scope of services. Appendix 2 - OC Sports and Wellness Itemized Fees Ongoing Primary Care is included with the Periodic Fee described in Appendix 1. Please see a list of some of the chronic conditions we routinely treat on the Practice website (subject to change). There are no itemized fees for office visitsvisits unless the patient has more than fifteen (15) scheduled in-office visits in a calendar year. In-Office Procedures we are generally comfortable performing are the procedures listed on the Practice website. These are typically available at no additional cost unless otherwise designated, and these are also subject to change. Laboratory Studies will be drawn in the office or lab center at a discounted no additional charge and the Patient will be charged according to the direct price rate we have negotiated with the lab. An example of common laboratory studies and their prices (subject to change) are listed on the practice website. Medications will be ordered in the most cost cost-effective manner possible for the Patient Patient. When we dispense medications in the office these medications will be made available to the patient at wholesale cost. Examples of commonly dispensed medications and their prices (subject to change) are listed on the practice website. Pathology studies (most commonly skin biopsies) will be ordered in the most economical manner possible. Anticipated prices for these studies (subject to change) are discounted at rate negotiated with listed on the labPractice website. Radiology studies will be ordered in rate negotiated with the labmost cost-effective manner possible for the Patient. Commonly ordered radiologic studies and prices (subject to change) are listed on the website. Surgery and specialist consults will be ordered in the most cost cost-effective manner possible for the Patient. Gynecological (Well Woman) exams are done at no additional cost. The anticipated cost of the pap smear (subject to change) will be listed on the website. Vaccinations are NOT offered in our office at this time due to the cost prohibitive nature of stocking a limited supply. We will make an effort to help you obtain needed vaccinations elsewhere else xxxx in the most cost cost-effective manner possible. Hospital Services are NOT covered by our membership plan, and due to mandatory “on call” duties required at local institutions we have elected NOT to obtain formal hospital admission privileges at this time. If you need to be hospitalized, you will be under the care of a Hospitalist. We will work collaboratively with your Hospitalist and coordinate your care following discharge from the hospital. Signed: DateObstetric Services are NOT covered by our membership plan.

Acceptance of Patients. We reserve the right to accept or decline patients based upon our capability to appropriately handle the patient’s primary care needs. We may decline new patients pursuant to the guidelines proffered in Section 6 (Term), because the Nurse PractitionerPhysician’s panel of patients is full (capped at 1,200 300 patients or fewer), or because the patient requires medical care not within the Nurse PractitionerPhysician’s scope of services. This area was intentionally left blank Agreement continues on the next page* Appendix 2 - Concierge Health Network Itemized Fees Ongoing Primary Care is included with the Periodic Fee described in Appendix 1. Please see a list of some of the chronic conditions we routinely treat on the Practice website or available at request (subject to change). There are no itemized fees for office visitsvisits unless the patient has more than twenty scheduled in-office or twenty scheduled virtual appointments in a calendar year. In-Office Procedures we are generally comfortable performing are listed on the Practice websitewebsite or are available at request. These are typically available at no additional the wholesale cost of supplies necessary for the procedures being provided unless otherwise designated, noted and these are also subject to change. Laboratory Studies will be drawn in the office at wholesale cost and the Patient will be charged accordingly. An example of common laboratory studies and their prices (subject to change) are listed on the practice website or lab center are available at a discounted rate negotiated with the labrequest. Medications will be ordered in the most cost effective manner possible for the Patient Patient. When we dispense medications in the office these medications will be made available to the patient at wholesale cost. Examples of commonly dispensed medications and their prices (subject to change) are listed on the practice website or are available at request. Pathology studies (most commonly skin biopsies) will be ordered in the most economical manner possible. Anticipated prices for these studies (subject to change) are discounted listed on the Practice website or are available at rate negotiated with the labrequest. Radiology studies will be ordered in rate negotiated with the labmost cost effective manner possible for the Patient. Commonly ordered radiologic studies and prices (subject to change) are listed on the website or are available at request. Surgery and specialist consults will be ordered in the most cost effective manner possible for the Patient. Vaccinations are NOT offered in our office at this time due to the cost prohibitive nature of stocking a limited supply. We will make an effort to help you obtain needed vaccinations elsewhere else xxxx in the most cost effective manner possible. Hospital Services are NOT covered by our membership plan, and due to mandatory “on call” duties required at local institutions we have elected NOT to obtain formal hospital admission privileges at this time. If you need Obstetric and Gynecologic Services are NOT covered by our membership plan. In the future we may begin to be hospitalizedoffer some of these outpatient services in our office, you will be under but due to our small size we are unable to offer these services at this time. I certify that I have read, understand, and agree to the care terms set forth in Concierge Health Network’s Direct Primary Care Agreement. I further certify that I have received a copy of a Hospitalistthis Agreement. We will work collaboratively with your Hospitalist All payments are due and coordinate your care following discharge from processed as outlined above. I certify that by providing my credit card or bank information through the hospital. Signed: Dateonline sign up, I authorize Practice and Physician to process payment as noted in the above Agreement.

Acceptance of Patients. We reserve the right to accept or decline patients based upon our capability to appropriately handle the patient’s primary care needs. We may decline new patients pursuant to the guidelines proffered in Section 6 (Term), because the Nurse PractitionerProvider’s panel of patients is full (capped at 1,200 patients or fewer)full, or because the patient requires medical care not within the Nurse PractitionerProvider’s scope of services. Appendix Patient Name Patient (Guardian) Signature Date (MM/DD/YYYY) APPENDIX 2 - Direct Primary Care (DPC) Itemized Fees Ongoing Primary Care Care: is included with the Periodic Fee described in Appendix 1. Please see a list of some of the acute and chronic conditions we routinely treat on the Practice website (website. Conditions we treat are subject to change). There are no itemized fees for office visits. In-Office Procedures we and Medications: A list of common procedures and associated fees, if any based upon membership status, is available upon request. Procedure fees are generally comfortable performing subject to change. Medications may be administered in our office via an injectable or oral route. Patient will incur an additional charge for these medications. Medication fees are listed on the Practice website. These are typically available at no additional cost unless otherwise designated, and these are also subject to change. Laboratory Studies Studies: We have the capability to draw blood for nearly any test you may need. Most lab specimens will be drawn in the office or lab center at a discounted rate negotiated with the labprocessed by an outside facility. Medications will be ordered in the most cost effective manner possible for the Patient at wholesale costA listing of some common laboratory tests and their fees are available upon request. This list is not comprehensive. Laboratory fees are subject to change. Pathology: Pathology studies (most commonly skin biopsiesbiopsies and Paps) will be ordered in the most economical manner possiblepossible and will be sent to an outside facility for analysis. Anticipated prices for these studies (Pathology fees are subject to change. Reflex Testing: Pricing for certain lab and pathology tests dependent on “reflex testing” (when a certain initial result requires additional testing on the same specimen) are discounted will not be known at rate negotiated with the time of specimen submission, therefore, lab/pathology pricing will not be known. The Patient will be charged for reflex testing once it is determined that a reflex test was required and performed on a specimen. Radiology: Radiology studies will be ordered in rate negotiated with the labmost cost-effective manner. We may provide certain Xray and ultrasound radiology Services on site. Prices will be disclosed to you at time of service. Pricing for all outside radiology referrals is determined by the organization you are being referred to. Surgery and specialist consults Specialist Consults: Referrals to Surgeons and Specialists will be ordered in the most cost cost-effective manner possible for the Patient. Pricing for all outside specialty referrals is determined by the organization you are being referred to. Vaccinations: Vaccinations are NOT offered in our office at this time due to the cost prohibitive nature of stocking a limited supply. We will make an effort to help you obtain needed vaccinations elsewhere in the most cost cost-effective manner possible. Hospital Services: Hospital Services are NOT covered provided by the Practice, and due to hospital rules and regulations, we have elected NOT to obtain formal hospital admission privileges for direct care at this time. Virtual Visits (Phone Visit and Televideo Visit): Practice may offer televideo and phone virtual visits to Patients. These visits typically are offered to Patients who have a minor condition that can be diagnosed with reasonable certainty without a face-to-face visit and to Patients who have had a recent visit which generated multiple lab abnormalities requiring further Provider consultation. This form of visit is offered by Provider discretion as a convenience to Patients where an office visit would normally be required. Virtual visit fees are included in the Monthly Periodic Fee. Other Services: Practice may add additional Services in the future. These will be posted on our membership planwebsite. If you need Patient Name Patient (Guardian) Signature Date (MM/DD/YYYY) RECEIPT OF NOTICE OF PRIVACY PRACTICES / ELECTRONIC COMMUNICATION / DISCLOSURE OF PHI / MESSAGES I, , have received a copy of Anovia Health, SC “Notice of Privacy Practices”. Patient’s Name Patient (Guardian) Signature Date (MM/DD/YYYY) I authorize Anovia Health, SC to be hospitalized, send email or text which may include unencrypted protected health information. (Providing us with authorization to email and text you will allow Anovia Health, SC to exchange information with you more efficiently and will benefit you as a patient. At the same time, we recognize that email and text messaging are not a completely secure means of communication. You are not required to authorize the use of email and text messages and a decision to not authorize electronic communication will not affect your health care in any way. We have taken considerable effort to protect the personal health information of our patients and recommend that all patients provide us with this authorization so that we can more efficiently communicate with them.) Name of Patient Patient (Guardian)Signature Date (MM/DD/YYYY) Our Practice takes Patient confidentiality and privacy very seriously but understands that certain Patients may wish for our Practice to disclose their “Protected Health Information” (PHI) to certain friends or family members to improve efficiency and delivery of health care Services. I authorize Anovia Health, SC to disclose my PHI (any information related to my care) to the following persons for the purpose of improving the delivery of healthcare Services to me. Name of Person: Relationship to Patient: Name of Person: Relationship to Patient: Phone #: Phone #: This authorization will remain in effect until I provide signed written notice to the Practice terminating this authorization. I do not have to sign this authorization in order to receive treatment from Anovia Health, SC. In fact, I have the right to refuse to sign this authorization. Refusal to sign this authorization will not affect my care in any way. When my information is used or disclosed pursuant to this authorization, it may be under subject to redisclosure by the care recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to Xxx Xxxxxxxx, Box 230, 0000 X. Xxxxxxx Ave. Green Bay, WI 54301 ph: (920) 310-8920 Name of Patient Patient (Guardian) Signature Date (MM/DD/YYYY) I authorize Anovia Health, SC to leave messages containing Protected Health Information on my answering machine/answering service/voicemail . Patient Signature Our practice may offer a virtual visit in place of a Hospitalistface to face visit for certain conditions that can safely be evaluated and treated either by phone or using telemedicine such as a televideo visit. We will work collaboratively with your Hospitalist and coordinate your care following discharge from the hospitalI consent to participation in telemedicine visits provided by Anovia Health, SC. Signed: DateName of Patient Patient (Guardian) Signature Date (MM/DD/YYYY)