Common use of Specialists Coordination Clause in Contracts

Specialists Coordination. The physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals to outside specialty care. The Patient understands that fees paid under this Agreement do not include or cover specialist's fees or charges from any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patient. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient Name Date of Birth Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 Patient Name Date of Birth Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 YES 🞎 NO Signature APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18-59 years of age $ 200 per month $ 60+ years of age $ 275 per month $ Total Monthly Membership Fee $ Enrollment Fee $150 per Member* (one time, non-refundable) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amount:

Specialists Coordination. The physician CLINIC and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staffCLINIC Physician. DIRECT PRIMARY CARE TIER OPTIONS The FOUNDATION (Maintenance Plan) The ESSENTIALS (Physician Services Plan) SIGNATURE LOTUS (All Inclusive Plan) Individual $60/month Family $150/month Individual $75/month Family $225/month Individual $125/month Family $325/month IDEAL FOR: ○ College students ○ Overall healthy individuals ○ Medication management ○ The technology savvy ○ Virtual appointments preferred IDEAL FOR: ○ Hormone Management ○ Patients with 1-2 medical diagnoses ○ Patients in need of more involved primary care ○ In-office visits preferred IDEAL FOR: ○ Hormone Management ○ Patients with 3+ medical diagnosis ○ Patients who may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement need more in depth treatment ○ In-office visits preferred WHAT IS INCLUDED? Unlimited Virtual Appointments Everything in The Foundation + Unlimited In-Office Visits (acute and payment shall always remain the sole responsibility of the Patient. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient Name Date of Birth Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 Patient Name Date of Birth Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 YES 🞎 NO Signature APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18-59 years of age $ 200 per month $ 60+ years of age $ 275 per month $ Total Monthly Membership Fee $ Enrollment Fee $150 per Member* (one time, non-refundacuteable) $ $Chronic Disease Management Executive Annual Exam (includes physical, EKG, and basic wellness labs - cholesterol, immune, electrolytes, liver, kidney, diabetes rule-out) Women's Wellness Annual Exam (including pap smear; lab fees for analysis may apply) Certain Injections (joint, toradol, trigger point) Monthly Acupuncture Appointment (includes one session 250 per coumonth, discounted rates for additional acupuncture visits are available) Everything ple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automThe Foundation + Everything in The Essentials + Choose One Per Month: Skin Laser Treatment OR Plasma Pen Treatment (2 square inch) One Annual Hormone Check (ZRT Saliva Test Kit; for established hormone patients) Additional Specialty Services as made available! Unlimited Communication with Lotus Health Simple Lab Testing (strepatic, reoccurring bilmonoling, simply complete the checking or debit/credit card information sections beurine, low and sign the form. Upon apprpregnancy) Minor In-Office Procedures (wart removaloval, we will automatically bill your checking account or debit/credit card for monthly fstitches, abscess draining, etc) Medication Management Basic Vision Screening Basic Annual Wellness Exam (labs are not included but are offered at a discounted rate) Discounted Rates with Select Venders (labs ees and related incidental chaanalysisrges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patiesupplements, medication, imagingnt(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal MediDiscounted Specialty Services (acupuncturecine, plasma pen treatmentP.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amoskin laser treatment)unt:

Specialists Coordination. The physician Physician shall coordinate with Patient’s with the their medical specialistsspecialists to assure continuity of care, and if requestednecessary, provide suitable referrals to outside shall assist in obtaining a referral for specialty care. The Patient understands that monthly fees paid under this Agreement do not include or cover specialist's ’s fees or charges from fees due to any outside medical professional other than professional. These are the Practice staff. Patients patient’s responsibility but Patient may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patientinsurance. APPENDIX B Electronic Communications CHECK PATIENT ENROLLMENT * Click box for YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATIONwhere indicated only if you agree to text message communication and provide email address only if you agree to Email communication. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX The fees as set out in the attached Appendix C, SHALL APPLY TO THE FOLLOWING MEMBER(Sshall apply to the following Patient(s), WHO BY SIGNING BELOW who by signing below, (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENTor) as Parent or Legal Guardian certify that they have read and agree to the terms and conditions of this Agreement: Patient 1 Print ____________________ ____ _______ ___ ________ ______ Patient Name Date of Birth Email ___________________________________________________________ _____________ Xxxxxx Xxxxxxx, Xxxx, Xxxxx, Xxx ________________ ________________ Home Phone Cell Phone Home Phone Email Agree Do you agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 Patient Name Date of Birth Cell Phone Home Phone Email Agree to Text Communication: (check one below): text message communication? 🞎 YES 🞎 NO Signature APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18-59 years of age $ 200 per month $ 60+ years of age $ 275 per month $ Total Monthly Membership Fee $ Enrollment Fee $150 per Member* (one time, non-refundable) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK/ Guardian ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routi_________________________ Dateng #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Inter__________ APPENDIX C FEE ITEMIZATION Individual Membership $_125.00__ per month One-time Non-refundable Enrollment Fee $_100.00__ Should Patient’s membership lapse or be terminated, and Patient later wishes to re-enroll, Patient will be accepted on a space available basis only, subject to a $250.00 re-activation fee. Patient Fees $_125.00__ Enrollment Fees $_100.00__ Total Amount Due $_225.00__ Total Monthly Amount Due $_125.00__ OR Individual Membership $_375.00__ per quarter (3 months) One-time Non-refundable Enrollment Fee $_100.00__ Should Patient’s membership lapse or be terminated, and Patient later wishes to re-enroll, Patient will be accepted on a space available basis only, subject to a $250.00 re-activation fee. Patient Fees $_375.00__ Enrollment Fees $_100.00__ Total Amount Due $_475.00__ Total Quarterly Amount Due $_375.00__ Appendix D Medicare Opt Out and Waiver Agreement This agreement (Agreement) is entered into by and between Mobile nal Medicine, PLLCP.and Xxxxxx Xxxx, MD (Provider), whose principal address is, 0000 Xxxx Xxxxxxxx Xxxxx, Xxxxx 0, Xxxxxxxxxx, Xxxxxxx 00000, and _____________________, a beneficiary enrolled in Medicare Part B pursuant C., to automatically bSection 4507 of ill the checking accoBalanced Budget Act of 1997 (“Beneficiary”), who resides at _____________________________________________________________________. The Practice and Provider have informed Patient that Provider has opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, unt or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amo1892 or any other section of the Social Security Act.unt:

Specialists Coordination. The physician PRACTICE and Provider shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientPRACTICE Provider. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(SPATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the following Patient(s), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN)who by signing below agree to the terms and conditions of the Xxxxxxxx X. Xxxxxx, CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 M.D., P.C. Medical Agreement Form. Print Patient Name Date of Birth (MM/DD/YYYY) Age Complete the following if they have not previously been entered online: Xxxxxx Xxxxxxx Xxxx, Xxxxx, Xxx Home Phone Cell Phone Home Phone Email Agree to Text CommunicationPreferred email Spouse/Family members whom this Agreement Applies: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienSpouse’s t Name Date of Birt(MM/DD/YYYY) Age Spouse’s Home Phone h Cell Phone Home PhonSpouse’s Preferred e Email AgreFamily Member’s Name Date of Birth (MM/DD/YYYY) Age Family Member’s Name Date of Birth (MM/DD/YYYY) Age Family Member’s Name Date of Birth (MM/DD/YYYY) Age Family Member’s Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □Yearly (Credit/Debit Card) □Monthly (Credit/Debit Card) *All patients must have a credit or debit card on file e to Text Communicaticover the cost of membership & any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in Xxxxxxxx X. Xxxxxx, M.D., P.C. Medical Agreement Form. I further certify that I have received a copy of this form. Signatureon: (check one below): 🞎 YES 🞎 NO SignatDate: ure APPENDIX C FEE ITEMIZATION Monthly Membership FeItemization Tier I – Services guaranteed to be provided by Xx. Xxxxxx: $80 a month single $100 a month family (Initial) Tier II – Services guaranteed to be provided by Nurse Practitioner: $60 a month single $80 a month family (Initial) Please initial option to apply to this agreement. Capital Family Practice Xxxxxxxx X. Xxxxxx, M.D., P.C. Board Certified Family Practice 0000 Xxxx Xxxxx Xxxxx #000 Xxxxxxx, Xxxxxxxx (000) 000e 18-59 years of age $ 200 per month $ 60+ years of age $ 275 per month $ Total Monthly Membership Fee $ Enrollment Fee $150 per Memb0000 Fax er* (one time,000) 000 non-refundable) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, sim0000 Please ply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECKbelow ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal MediXxxxxxxx X. Xxxxxxcine, M.D.P.P.C. C., to automatically bill the checking accountcharge my or credit/debit card listed aindicated below for amount agreed to in the contract on the first of each month for the duration of the contract. [ ] DISCOVER [ ] VISA [ ] MASTER CARD CHECK CARD USED CARD NUMBER Exp. Date Billing Address Phone# CityboState, Zip Email SIGNATURE DATE I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Xxxxxxxx X. Xxxxxx, M.D., P.C. in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account ve, as specisoon as the above noted periodic transaction datesfied. ProIn the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that Xxxxxxxx X. Xxxxxx, M.D., P.C. may at its discretion attempt to process the charge again within 30 days, and agree to an additional $30.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit cardduct/Service Description: Medical Services Recurring Amobank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form. . Please return signed contract and auto payment agreement to Capital Family Practice. You will be charged for the first month to reserve your membership. Your card will not be charged again until May 1, 2018. Thank you,unt:

Specialists Coordination. The physician CLINIC and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientCLINIC Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(SPATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the following Patient(s), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient who by signing below agree to the terms and conditions of the ROGUE DIRECT PRIMARY CARE Medical Agreement Form. Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children (at least 16 years of age) e to Text Communicatiwhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □ Monthly (Credit/Debit Card/Bank Draft) □ Employer *All patients must have a credit or debit card on Tile to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in ROGUE DIRECT PRIMARY CARE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: ure APPENDIX C FEE ITEMIZATION Monthly MembersIndividual $85 per month Couple $160 per month* Family $240 per month** Re-enrollment hip Fee 18-59 years of ag$e $ 200 per month $ 60+ years of age $ 275 per month $ Total Monthly Membership Fee $ Enrollment Fee $150 per Mehousehold**mber* (one time, non-refundable) $ $250 per cou*Couple must reside plethe in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION household. **Up to four members in For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreesame householdment. You will recebe charged $50 per month for each additional family member. Each family member has to be at least 18 years of age. ***Non-refundable fee. Should your membership lapse or be terminated, ive a detailed statement prre-enrollment fee must be paid for membership iorbecome active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ APPENDIX D MEDICARE OPT OUT AND WAIVER AGREEMENT This agreement (Agreement) is entered into by and between Rogue Direct Primary Care, an Oregon Limited Liability Company, Xx. Xxx Xxxxxxx Olshausen (Physician), whose principal address is 0000 Xxxxxxx Xxxx Xxxxx, Xxxxx 000, Xxxxxxx, Xxxxxx 00000, and , a beneTiciary enrolled in Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997 (BeneTiciary), who resides at , , OR . The Physician has informed Patient that Physician has opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Cardother section of the Social #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoAct.unt:

Specialists Coordination. The physician PRACTICE and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientPRACTICE Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Monthly fees, as set out in Appendix C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient shall apply to the following Patient(s): Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □ Monthly (Credit/Debit Card/Bank Draft) □ Annually (Credit/Debit Card/Bank Draft/Check) *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. ure APPENDIX C FEE ITEMIZATION Monthly Membership Fe6e 1824 -59 years of age $ $39 per month* 25-49 years of age $79 200 per month 50$ 60+ years of age $ $99 275 per month $ Total Monthly Membership Fee $ Enrollment Fee $150 per Me150*mbe*Patients under 18 require the enrollment of at least r* (one adult member. **Non-refundable fee. Should your membership lapse or be terminatedtime, non-refundable) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit cenrollment fee must be paid again ard for monthly fees and related incidental charges, pursumembership ant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amobecome active.unt:

Specialists Coordination. The physician shall coordinate Patient’s care with medical specialists and other practitioners to whom the their medical specialists, and if requested, provide suitable referrals to outside specialty carePatient needs referral. The Patient understands that fees paid under this Agreement do not include or cover specialist's fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patient. APPENDIX B Electronic Communications PATIENT ENROLLMENT FORM PATIENT ENROLLMENT FORM CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(SPATIENT(S), WHO BY SIGNING BELOW (( OR AS A LEGAL GUARDIANREPRESENTATIVE), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient Name Date of Birth Street Address City, State, Zip Cell Phone Home Alternate Number Email I Agree to Text Communication: (check one below) 🞎 Yes 🞎 No Printed Name: Relationship to Patient: Patient 2 Patient Name Date of Birth Cell Phone Alternate Number Email I agree to Text Communication: (check one below) 🞎 YES 🞎 NO Printed Name: Relationship to Patient: Patient 3 Patient Name Date of Birth Cell Phone Alternate Number Email Agree to Text Communication: (check one below): ) 🞎 YesYES �� No SignatuNO Printed Name: Relationship to Patientre: Patient 4 2 Patient Name Date of Birth Cell Phone Home PhonAlternate Number e Email AgreI agree e to Text Communication: (check one below)) : 🞎 YES 🞎 NO SignatPrinted Name: Relationship to Patient: Enrollment fee ure APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18-59 years of age $ 200 per month $ 60+ years of age $ 275 per month $ Total Monthly Membership Fee $ Enrollment Fee $150 per MembeThere is a r* (one time, non-refundablenonrefundable enrollment fee of ) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amo60.unt:

Specialists Coordination. The physician CLINIC and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staffCLINIC Physician. Patients may submit such charges APPENDIX 2 PATIENT ENROLLMENT – AGREEMENT FORM XXXXXXXXX CHIROPRACTIC CENTER Annual fees as set out below shall apply to their health care plan for reimbursement considerationthe following Patient(s), but we cannot guarantee reimbursement who by signing below agree to the terms and payment shall always remain the sole responsibility conditions of the PatientXXXXXXXXX CHIROPRACTIC CENTER Agreement Form. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □ Yearly (Credit/Debit Card) □ Monthly (Credit/Debit Card/Check) □ Employer *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in XXXXXXXXX CHIROPRACTIC CENTER Agreement Form. I further certify that I have received a copy of this form. Signature: ure APPENDI3 X C FEE ITEMIZATION Monthly Membership Fee 18-59 years of age $ 200 per month 19$ 60+ years of age $ $50 275 per mo0-18 years of age $10 per visit* $50/Month – Member receives 2 visits at no extra charge and $10 for every visit thereafter. *With the enrollment of at least one adult member. Patient 1 nth $ Total Monthly Membership Fee $ Enrollment Fee $150 per Member* (one time, non-refundable) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amo2 Additional Patientsunt:

Specialists Coordination. The physician Physician shall coordinate Patient’s with medical specialists to whom the their medical specialists, and if requested, provide suitable referrals Patient is referred to outside assist the Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientPhysician. APPENDIX B Electronic Communications PATIENT ENROLLMENT FORM CHECK YES WHERE W HERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. COMMUNICATION AND PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. YOUR SIGNATURE INDICATES ACCEPTANCE OF THE TERMS OF THE PATIENT AGREEMENT. THE FEES AS SET OUT IN THE ATTACHED APPENDIX XXXXX XXX C, SHALL APPLY TO THE FOLLOWING MEMBER(SFOLLOWIN G PATIENT(S), WHO BY SIGNING BELOW (OR AS A PARENT OR LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient Name Date of Birth Street Address City, State, Zip Work Phone Cell Phone or Home Phone Email Agree to Text Communication: YES NO (check one below): 🞎 Yes 🞎 None) o Signature: Patient 2 Patient Name Date of BirtStreet Address City, State, Zip Work Phone h Cell Phonor e Home Phone Email Agree to Text CommunicationYES NO : (check one below): one) Signature CHILD/CHILDREN TO W HOM THIS AGREEMENT APPLIES: PRINT NAME DATE OF BIRTH MM DD YYYY PRINT NAME DATE OF BIRTH MM DD YYYY PRINT NAME DATE OF BIRTH MM DD YYYY DO YOU AGREE TO TEXT MESSAGE COMMUNICATION IN REGARD TO THE ABOVE NAMED CHILDREN? (CHECK ONE) ! 🞎 YES! 🞎 NO SignatPARENT/GUARDIAN: PRINTED NAME SIGNATURE: _ DATE: _ REALTIONSHIP TO PATIENT/S: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fe0e 1825 -59 years of age $ 50 200 per month 26-49 years of age $ 75 per month 50$ 60+ years of age $ $100 275 per month $ Total Monthly Membership Fee $ Enrollment Fee $One Time Non-Refundable $ 99 150 per Member* (one time,family $ Re non-refundable) $ $250 per couple in same household Total Enrollment FePatient shall be accepted back into the Practice, if desires, after allowing membership to lapse or be terminated, on a space-available basis, and subject to a $225 re-enrollment fee. e $ Initial Payment Total MontProrated hly Membership Fees Fee $ Total Enrollment FeFees e $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoPaymentunt:

Specialists Coordination. The physician CLINIC and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientCLINIC Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(SPATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the following Patient(s), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 who by signing below agree to the terms and conditions of the KANSAS CITY DIRECT PRIMARY CARE Medical Agreement Form. Print Patient Name Date of Birth (MM/DD/YYYY) Age Complete the following if they have not previously been entered online: Xxxxxx Xxxxxxx Xxxx, Xxxxx, Xxx Home Phone Cell Phone Home Phone Email Agree Preferred email Spouse/Child/Children to Text CommunicationWhom this Agreement Applies: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienSpouse’s t Name Date of Birt(MM/DD/YYYY) Age Spouse’s Home Phone h Cell Phone Home PhonSpouse’s Preferred e Email AgreChild’s Name Date of Birth (MM/DD/YYYY) Age Child’s Name Date of Birth (MM/DD/YYYY) Age Child’s Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □ Yearly (Credit/Debit Card) □ Monthly (Credit/Debit Card) □ Employer-sponsored plan: *All patients must have a credit or debit card on file e to Text Communicaticover the cost of membership & any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in KANSAS CITY DIRECT PRIMARY CARE Medical Agreement Form. I further certify that I have received a copy of this form. Signatureon: (check one below): 🞎 YES 🞎 NO SignatDate: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fe0e 1818 -59 years of age $ $30 per month* 0-18 years of age $65 per month** 19 - 25 years of age $45 per month* 19 - 25 years of age $65 per month** 26-49 years of age $65 200 per month 50 - 64 years of age $75 per month 65$ 60+ years of age $ $90 275 per month $ Total Monthly MembersFamily Rate $140 per month (2 adults + children; spanning 2 generations) Enrollment hip Fe$75 per account*** Re-e $ Enrollment Fee $150 per Meaccount**mbeOngoing Rates: *With the enrollment of at least r* (one adult member. **Without an enrolled adult member. ***Non-refundable fee. Should your membership lapse or be terminatedtime,the re non-refundabenrollment fee must be paid again for membership to become active. Patient 1 le) $ $250 per couple in same household ToPatient 2 $ Patient 3 $ Patient 4 $ Additional $ TOTAL RATE $ One-time enrollment costs: tal Enrollment Fee $ Initial Payment Total Monthly Membership Prorate of Current Month Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amoperunt:

Specialists Coordination. The physician MODERN MOBILE MEDICINE and its Physicians shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patienta MODERN MOBILE MEDICINE Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(SPATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the following Patient(s), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient who by signing below agree to the terms and conditions of the MODERN MOBILE MEDICINE Medical Agreement Form. Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print NamePreferred Payment Method*□ Yearly (Check Only) Date of Birth (MM/DD/YYYY) Age □ Monthly (Credit/Debit Card/Check) □ Employer *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in MODERN MOBILE MEDICINE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18-59 years of age $ 200 – PLUS MEMBERSHIP Individual $149/per month $ 60+ years of age $ 275 per month $ Total Monthly Membership FeAfter-­‐hours/Weekend Telemedicine Surcharge $20/consultation After-­‐hours/Weekend House Calls Surcharge $150/visit e $ Enrollment Fee $150 per Me99/individualmbAdditional Telemedicine Consults $20/each Additional House Calls $75/each *Non-­‐refundable fee. Should your membership lapse or be terminated, the enrollment fee must be paid again for membership to become active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ APPENDIX D MEDICARE OPT OUT AND WAIVER AGREEMENT This agreement er* (one Agreement) is entered into by and between Xxxxxxx Xxxxx MDtime, non-refundable) $ $250 per couLLC d/b/a Modern Mobile Medicine, an Arizona Limited Liability Company, Xx. Xxxxxxx Xxxxx and Xx. Xxxxxxxxxx Xxxxx (collectively “Physicians”), whose principal address is 000 Xxxxxx Xxxxxx #545, Alexandria, Virginia 22305, and , a beneficiary enrolled ple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental chargMedicare Part B es, pursuant to AppendiSection 4507 x C of ythe Balanced Budget Act of 1997 (Beneficiary), who resides at . The Physicians have informed our Patient Agreement. You will receive a detailed statement priorthat Physicians have opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Cardother section of the Social #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoAct.unt:

Specialists Coordination. The physician MODERN MOBILE MEDICINE and its Physicians shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than a MODERN MOBILE MEDICINE Physician. INDIVIDUAL PREMIUM APPENDIX B PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the Practice staff. Patients may submit such charges following Patient(s), who by signing below agree to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement the terms and payment shall always remain the sole responsibility conditions of the PatientMODERN MOBILE MEDICINE Medical Agreement Form. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print NamePreferred Payment Method*□ Yearly (Check Only) Date of Birth (MM/DD/YYYY) Age □ Monthly (Credit/Debit Card/Check) □ Employer *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in MODERN MOBILE MEDICINE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18-59 years of – PREMIUM MEMBERSHIP Individual $279/month After-­‐hours/Weekend House Calls Surcharge $99/visit Additional House Calls $50/each Patient 1 age $ 200 per moPatient 2 Additional Patients TOTAL RATE nth $ 60+ years of age $ 275 per month $ Total Monthly Membership Fee $ Enrollment Fee $150 per MembAPPENDIX D MEDICARE OPT OUT AND WAIVER AGREEMENT This agreement er* (one Agreement) is entered into by and between Xxxxxxx Xxxxx MDtime, non-refundable) $ $250 per couLLC d/b/a Modern Mobile Medicine, an Arizona Limited Liability Company, Xx. Xxxxxxx Xxxxx and Xx. Xxxxxxxxxx Xxxxx (collectively “Physicians”), whose principal address is 000 Xxxxxx Xxxxxx #545, Alexandria, Virginia 22305, and , a beneficiary enrolled ple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental chargMedicare Part B es, pursuant to AppendiSection 4507 x C of ythe Balanced Budget Act of 1997 (Beneficiary), who resides at . The Physicians have informed our Patient Agreement. You will receive a detailed statement priorthat Physicians have opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Cardother section of the Social #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoAct.unt:

Specialists Coordination. The physician CLINIC and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientCLINIC Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(SPATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the following Patient(s), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient who by signing below agree to the terms and conditions of the ACCESS FAMILY MEDICINE Medical Agreement Form. Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □ Monthly □ Quarterly □ Semi-Annually □ Annually □ Employer *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in the ACCESS FAMILY MEDICINE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fe0e 1819 -59 years of age $ $10 per month* 0-19 years of age $50 per month** 20-44 years of age $50 200 per month 45-64 years of age $75 per month 65$ 60+ years of age $ $100 275 per month $ Total Monthly Membership FeRe-e $ Enrollment Fee $200 150 per Mehousehold**mb*With the enrollment of at least one adult member. **Without a fully enrolled adult member. ***Non-refundable fee. Should your membership lapse or be terminated, the re-enrollment fee must be paid again for membership to become active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ APPENDIX D MEDICARE OPT OUT AND WAIVER AGREEMENT This agreement er* (one Agreement) is entered into by and between Access Enterprisetime, non-refundable) $ $250 per coua Nebraska Limited Liability Company, d/b/a Access Family Medicine, Dr. Xxxx Xxxxxxx (Physician), whose principal address is 0000 X Xxxxxx, Xxxxx 000, Xxxxxxx, Xxxxxxxx 00000, and , a beneficiary enrolled ple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental chargMedicare Part B es, pursuant to AppendiSection 4507 x C of ythe Balanced Budget Act of 1997 (Beneficiary), who resides at , , NE . The Physician has informed our Patient Agreement. You will receive a detailed statement priorthat Physician has opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Cardother section of the Social #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoAct.unt:

Specialists Coordination. The physician Physician shall coordinate with Patient’s with the their medical specialistsspecialists to assure continuity of care, and if requestednecessary, provide suitable referrals to outside shall assist in obtaining a referral for specialty care. The Patient understands that monthly fees paid under this Agreement do not include or cover specialist's ’s fees or charges from fees due to any outside medical professional other than professional. These are the Practice staff. Patients patient’s responsibility but Patient may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patientinsurance. APPENDIX B Electronic Communications CHECK PATIENT ENROLLMENT * Click box for YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATIONwhere indicated only if you agree to text message communication and provide email address only if you agree to Email communication. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX The fees as set out in the attached Appendix C, SHALL APPLY TO THE FOLLOWING MEMBER(Sshall apply to the following Patient(s), WHO BY SIGNING BELOW who by signing below, (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENTor) as Parent or Legal Guardian certify that they have read and agree to the terms and conditions of this Agreement: Patient 1 Print Primary Patient Name Date of Birth Street Address City, State, Zip Home Phone Cell Phone Home Phone Email Agree Do you agree to Text Communicationtext message communication? YES NO Signature of Patient / Guardian: (check one below): 🞎 Yes 🞎 No SignatuDatere: Patient Secondary 2 Patient Nam(If applicable) e Date of BirtStreet Address City, State, Zip Home Phone h Cell Phone Home Phone Email AgreDo you agree e to Text Communication: (check one below): text message communication? 🞎 YES 🞎 NO Signatof Patient / Guardian: Date: Child (1) Print Name (If applicable) Date of Birth Child (2) Print Name (If applicable) Date of Birth Child (3) Print Name (If applicable) Date of Birth Signature of Parent / Guardian: Date: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18-59 years of Two or more Members age $ 129.00 200 per moper individual One-time Non-refundable Enrollment Fee nth $ 60+ years of 100.00 per individual Should Patient’s membership lapse or be terminated, and Patient later wishes to re-enroll, Patient will be accepted on a space available basis only, subject to a $250.00 re-activation fee. Patient 1 age $ 275 per moPatient 2 $ Patient 3 $ Patient 4 $ Patient 5 $ Enrollment Fees $ Total Amount Due nth $ Total Monthly Membership Amount Due Fee $ Enrollment Fee $150 per MembAppendix D Medicare Opt Out and Waiver Agreement This agreement er* (one Agreement) is entered into by and between Mobile Medicinetime, non-refundable) $ $250 per couPLLC, and Xxxxxx Xxxx, MD (Provider), whose principal address is, 00000 X. Xxx Xxxxx Xxxxx 1091 Scottsdale, Arizona 85258, and , a beneficiary enrolled ple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental chargMedicare Part B es, pursuant to AppendiSection 4507 x C of ythe Balanced Budget Act of 1997 (“Beneficiary”), who resides at . The Practice and Provider have informed our Patient Agreement. You will receive a detailed statement priorthat Provider has opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Cardother section of the Social #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoAct.unt:

Specialists Coordination. The physician PRACTICE and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientPRACTICE Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Monthly fees, as set out in Appendix C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient shall apply to the following Patient(s): Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method (circle one)* Credit Card Debit Card Bank Draft *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in this Medical Agreement Form. Signature: _ ure APPENDIX C FEE ITEMIZATION Monthly Membership Fe0e 1819 -59 years of age $ $10 per month* 0-19 years of age $50 per month** 20-49 years of age $50 200 per month 50-64 years of age $75 per month 65$ 60+ years of age $ $100 275 per month $ Total Monthly Membership Fee $ Enrollment Fee $150 per Meperson, not to exceed $300 per household**mb*With the enrollment of at least one adult member. **Without a fully enrolled adult member. ***Non-refundable fee. Should your membership lapse or be terminated, the enrollment fee must be paid again for membership to become active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ APPENDIX D MEDICARE OPT OUT AND WAIVER AGREEMENT This agreement er* (one Agreement) is entered into by and between Octagram Direct Primary Caretime, non-refundable) $ $250 per coua Pennsylvania Professional Limited Liability Company, Xx. Xxxxx Xxxxxx (Physician), whose principal address is 000 Xxxxxx Xxxxxx Xxxx, Xxxxx 000X, Xxxxxxx, Xxxxxxxxxxxx 00000, and , a beneficiary enrolled ple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental chargMedicare Part B es, pursuant to AppendiSection 4507 x C of ythe Balanced Budget Act of 1997 (Beneficiary), who resides at , , PA . The Physician has informed our Patient Agreement. You will receive a detailed statement priorthat Physician has opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Cardother section of the Social #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoAct.unt:

Specialists Coordination. The physician CLINIC and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientCLINIC Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Monthly fees, as set out in Appendix C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient shall apply to the following Patient(s): Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □ Yearly (Credit/Debit Card/Bank Draft) □ Monthly (Credit/Debit Card/Bank Draft) *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in this Medical Agreement Form. Signature: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fe0e 1818 -59 years of age $ $15 per month* 19-44 years of age $50 200 per month 45-64 years of age $75 per month 65$ 60+ years of age $ $100 275 per month $ Total Monthly Membership Fee $ EnrollmReenrollment ent Fee $99 150 per Meperson $199 per family*mbe*With the enrollment of at least r* (one adult member. **Non-refundable fee. Should your membership lapse or be terminatedtime, non-refundabthe reenrollment fee must be paid for membership to become active. Patient 1 le) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amo2 Additional Patientsunt:

Specialists Coordination. The physician MODERN MOBILE MEDICINE and its Physicians shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patienta MODERN MOBILE MEDICINE Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(SPATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the following Patient(s), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient who by signing below agree to the terms and conditions of the MODERN MOBILE MEDICINE Medical Agreement Form. Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print NamePreferred Payment Method*□ Yearly (Check Only) Date of Birth (MM/DD/YYYY) Age □ Monthly (Credit/Debit Card/Check) □ Employer *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in MODERN MOBILE MEDICINE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18-59 years of age $ 200 – FAMILY MEMBERSHIP Family $199/per month $ 60+ years of age $ 275 per month $ Total Monthly Membership FeAfter-­‐hours/Weekend Telemedicine Surcharge $20/consultation After-­‐hours/Weekend House Calls Surcharge $150/visit e $ Enrollment Fee $150 per Me99/family membermbAdditional Telemedicine Consults $20/each Additional House Calls $75/each *Non-­‐refundable fee. Should your membership lapse or be terminated, the enrollment fee must be paid again for membership to become active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ APPENDIX D MEDICARE OPT OUT AND WAIVER AGREEMENT This agreement er* (one Agreement) is entered into by and between Xxxxxxx Xxxxx MDtime, non-refundable) $ $250 per couLLC d/b/a Modern Mobile Medicine, an Arizona Limited Liability Company, Xx. Xxxxxxx Xxxxx and Xx. Xxxxxxxxxx Xxxxx (collectively “Physicians”), whose principal address is 000 Xxxxxx Xxxxxx #545, Alexandria, Virginia 22305, and , a beneficiary enrolled ple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental chargMedicare Part B es, pursuant to AppendiSection 4507 x C of ythe Balanced Budget Act of 1997 (Beneficiary), who resides at . The Physicians have informed our Patient Agreement. You will receive a detailed statement priorthat Physicians have opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Cardother section of the Social #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoAct.unt:

Specialists Coordination. The physician Physician shall coordinate with Patient’s with the their medical specialistsspecialists to assure continuity of care, and if requestednecessary, provide suitable referrals to outside shall assist in obtaining a referral for specialty care. The Patient understands that monthly fees paid under this Agreement do not include or cover specialist's ’s fees or charges from fees due to any outside medical professional other than professional. These are the Practice staff. Patients patient’s responsibility but Patient may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patientinsurance. APPENDIX B Electronic Communications CHECK PATIENT ENROLLMENT * Circle YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATIONwhere indicated only if you agree to text message communication and provide email address only if you agree to Email communication. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX The fees as set out in the attached Appendix C, SHALL APPLY TO THE FOLLOWING MEMBER(Sshall apply to the following Patient(s), WHO BY SIGNING BELOW who by signing below (OR AS A LEGAL GUARDIANor as parent or legal guardian), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENTcertify that they have read and agree to the terms and conditions of this Agreement: Patient 1 Print Patient Name Date of Birth Street Address City, State, Zip Home Phone Cell Phone Home Phone Email Do you Agree to Text Communication: text message communication? YES NO (check one below): 🞎 Yes 🞎 NCircle one) o Signature: Patient Date 2 Patient Name Date of BirtHome Phone h Cell Phone Home Phone Email AgreDo you agree e to Text Communicatitext message communication? YES NO (Circle one) SignatureonDate Child/Children to Whom this Agreement Applies: Print Name Date of Birth : (check one below): MM/DD/YYYY) Print Name Date of Birth (MM/DD/YYYY) Print Name Date of Birth (MM/DD/YYYY) Do you agree to text message communication in regard to the above named children to and from the cell phone number written above or any other number provided to Us? 🞎 YES 🞎(Circle one) NO Signatparent or guardian _ Date _ RELATIONSHIP: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18Individual $ 75 per month Family Membership* $250 per month *2 Adults and 2 Dependents <26 -59 years of ) Non-refundable one-time enrollment fee age $ 200 per mo75. Individual $150 Family Patient 1 nth $ 60+ years of age $ 275 per moPatient 2 Additional Patients Enrollment Fees TOTAL AMOUNT DUE nth $ ToContinuing tal Monthly Membership Fee $ Enrollment Fee $150 per MembAppendix D Medicare Opt Out and Waiver Agreement This agreement er* (one Agreement) is entered into by and between Envision Health LLC time, non-refundable) $ $250 per couXxxxxxxx X. Xxx, DO(Provider), whose principal address is, 000 Xxxxx Xxxx Xxxxxx, Xxxxx 0X, Xxxxx Xxxxx, Xxxxxxx 00000, and , a beneficiary enrolled ple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental chargMedicare Part B es, pursuant to AppendiSection 4507 x C of ythe Balanced Budget Act of 1997 (“Beneficiary”), who resides at , . The Provider has informed our Patient Agreement. You will receive a detailed statement priorthat Provider has opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Cardother section of the Social #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoAct.unt:

Specialists Coordination. The physician CLINIC and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientCLINIC Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(SPATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the following Patient(s), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 who by signing below agree to the terms and conditions of the KANSAS CITY DIRECT PRIMARY CARE Medical Agreement Form. Print Patient Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Cell Phone Home Phone Email Agree Preferred email Spouse/Child/Children to Text Communication: Whom this Agreement Applies (check one belowi.e. those enrolling for care): 🞎 Yes 🞎 No Signature: Patient 2 PatienSpouse’s t Name Date of Birt(MM/DD/YYYY) Age Spouse’s Home Phone h Cell Phone Home PhonSpouse’s Preferred e Email AgreChild’s Name Date of Birth (MM/DD/YYYY) Age Child’s Name Date of Birth (MM/DD/YYYY) Age Child’s Name Date of Birth (MM/DD/YYYY) Age Child’s Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □ Yearly (Credit/Debit Card) □ Monthly (Credit/Debit Card) *All patients must have a credit or debit card on file e to Text Communicaticover the cost of membership & any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in KANSAS CITY DIRECT PRIMARY CARE Medical Agreement Form. I further certify that I have received a copy of this form. Signatureon: (check one below): 🞎 YES 🞎 NO SignatDate: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fe0e 1818 -59 years of age $ $30 per month* 0-18 years of age $65 per month** 19 - 25 years of age $45 per month* 19 - 25 years of age $65 per month** 26 - 64 years of age $65 200 per month 65$ 60+ years of age $ $90 275 per month $ Total Monthly MembersFamily Rate $140 per month (2 adults + children; spanning 2 generations) Enrollment hip Fe$75 per account*** Re-e $ Enrollment Fee $150 per Meaccount**mbeOngoing Rates: *With the enrollment of at least r* (one adult member. **Without an enrolled adult member. ***Non-refundable fee. Should your membership lapse or be terminatedtime,the re non-refundabenrollment fee must be paid again for membership to become active. Patient 1 le) $ $250 per couple in same household ToPatient 2 $ Patient 3 $ Patient 4 $ Additional $ TOTAL RATE $ One-time enrollment costs: tal Enrollment Fee $ Initial Payment Total Monthly Membership Prorate of Current Month Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amoperunt:

Specialists Coordination. The physician MODERN MOBILE MEDICINE and its Physicians shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patienta MODERN MOBILE MEDICINE Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(SPATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the following Patient(s), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient who by signing below agree to the terms and conditions of the MODERN MOBILE MEDICINE Medical Agreement Form. Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print NamePreferred Payment Method*□ Yearly (Check Only) Date of Birth (MM/DD/YYYY) Age □ Monthly (Credit/Debit Card/Check) □ Employer *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in MODERN MOBILE MEDICINE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18-59 years of age $ 200 – FAMILY PREMIUM MEMBERSHIP Family $399/per month $ 60+ years of age $ 275 per month $ Total Monthly Membership FeAfter-­‐hours/Weekend House Calls Surcharge $99/visit e $ Enrollment Fee $150 per Me199/familymbAdditional House Calls $50/each *Non-­‐refundable fee. Should your membership lapse or be terminated, the enrollment fee must be paid again for membership to become active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ APPENDIX D MEDICARE OPT OUT AND WAIVER AGREEMENT This agreement er* (one Agreement) is entered into by and between Xxxxxxx Xxxxx MDtime, non-refundable) $ $250 per couLLC d/b/a Modern Mobile Medicine, an Arizona Limited Liability Company, Xx. Xxxxxxx Xxxxx and Xx. Xxxxxxxxxx Xxxxx (collectively “Physicians”), whose principal address is 000 Xxxxxx Xxxxxx #545, Alexandria, Virginia 22305, and , a beneficiary enrolled ple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental chargMedicare Part B es, pursuant to AppendiSection 4507 x C of ythe Balanced Budget Act of 1997 (Beneficiary), who resides at . The Physicians have informed our Patient Agreement. You will receive a detailed statement priorthat Physicians have opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Cardother section of the Social #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoAct.unt:

Specialists Coordination. The physician PRACTICE and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientPRACTICE Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Monthly fees, as set out in Appendix C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient shall apply to the following Patient(s): Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method (circle one)* Credit Card Debit Card Bank Draft *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in this Medical Agreement Form. Signature: _ $89 ure APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18-59 years of age $ Per Patient $99.99 200 per month $ 60+ years of age $ 275 per month $ Total Monthly Membership Fee $ Enrollment F99 per person, up to $ee $150 per Mehouseholdmber* (one *Non-refundable fee. Should your membership lapse or be terminatedtime, non-refundabthe enrollment fee must be paid again for membership to become active. Patient 1 le) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amo2 Additional Patientsunt:

Specialists Coordination. The physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals to outside specialty care. The Patient understands that fees paid under this Agreement do not include or cover specialist's fees or charges from any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patient. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient Name Date of Birth Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 Patient Name Date of Birth Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 YES 🞎 NO Signature APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18-59 years of age $ 200 per month $ 60+ years of age $ 275 per month $ Total Monthly Membership Fee $ Enrollment Fee $150 per Member* (one time, non-refundable) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal MediMedicine NOTICE OF PRIVACY PRACTICES This notice describes how health information about you may be used and disclosedcine, P.and how you can gain access C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amoyour individually identifiable health information.unt:

Specialists Coordination. The physician CLINIC and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientCLINIC Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(SPATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Fees as set out below shall apply to the following Member(s), WHO BY SIGNING BELOW who by signing below agree to the terms and conditions of the KANSAS CITY DIRECT PRIMARY CARE Medical Agreement Form. Member’s Printed Name (OR AS A LEGAL GUARDIAN)Head of Household) Date of Birth (MM/DD/YYYY) Age Street Address City, CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient State, Zip Home Phone Cell Phone Preferred email Spouse/Child/Children to Whom this Agreement Applies (i.e. those enrolling for care): Spouse’s Name Date of Birth (MM/DD/YYYY) Age Spouse’s Home Phone Cell Phone Home Phone Spouse’s Preferred Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienChild’s t Name Date of Birth Cell Phone Home Phone Email Agre(MM/DD/YYYY) Age Child’s Name Date of Birth (MM/DD/YYYY) Age Child’s Name Date of Birth (MM/DD/YYYY) Age Child’s Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* Employer-sponsored plan: □ Yearly (Credit/Debit Card) □ Monthly (Credit/Debit Card) *All patients must have a credit or debit card on file e to Text Communicaticover the cost of membership & any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in KANSAS CITY DIRECT PRIMARY CARE Medical Agreement Form. I further certify that I have received a copy of this form. Signatureon: (check one below): 🞎 YES 🞎 NO SignatDate: ure APPENDIX C FEE ITEMIZATION Monthly MembersStandard KCDPC hip FeItemization per Member: 0e 1818 -59 years of age $ $30 per month* 0-18 years of age $65 per month** 19 - 25 years of age $45 per month* 19 - 25 years of age $65 per month** 26 - 64 years of age $65 200 per month 65$ 60+ years of age $ $90 per month*** Family Rate $140 275 per month $ Total Monthly Membership Fee $ Enrollment Fee $Two adults and children 18 years old or younger spanning two generations *With the enrollment of at least one parent member. **Without an enrolled parent member. ***Medicare-eligible employees may not enroll 150 per Membsection 5, above. YOUR EMPLOYER WILL PAY KANSAS CITY DIRECT PRIMARY CARE FOR THIS MONTHLY FEE ON YOUR BEHALF. Your employer may or may not be covering all or part of this fee as an employee benefit; contact your employer directly for details. If your Employer terminates their contract with KCDPC or if you are terminated from your position with your Employer, you will be charged the full amount of your monthly membership, as delineated above, to the payment form on file with us. You will be given notice prior to this occurring and may terminate your membership as detailed in paragraph 5 of this agreement. ______ er* (one time, non-refundInitialable) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMACREDIT/DEBIT CARD TIC BILLING AUTHORIZATION To enjoy For the convenience of automatic, reoccurrautomated ing billing, simply complete the checking or dCreditebit/credit card information sectiDebit Card Information section ons below and sign the foAll requested information is required. rm. Upon approval,you we will automatically bhave the option to make monthly payments or set up a monthly auto-deduction. Payments are made directly through our secure link accessed through ill your checking account or debit/credit card electronic statement sent to your email. Your statement will include for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. which you You will receive a detailed statement prior to any paympayments or ent deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATPAYMENT INFORMATION ION I authorize Integrate Internal Medicine, P.KANSAS CITY DIRECT PRIMARY CARE C., to automatically bxxxx and charge ill the checking account or credit/debit card listed abobelow ve, as specified. Product/Service Description: Medical Services Recurring Amount:

Specialists Coordination. The physician CLINIC and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staffCLINIC Physician. Patients may submit such charges APPENDIX 2 PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM GATEWAY MEDICAL PRACTICE, LLC d/b/a CLARII HEALTH Annual fees as set out below shall apply to their health care plan for reimbursement considerationthe following Patient(s), but we cannot guarantee reimbursement who by signing below agree to the terms and payment shall always remain the sole responsibility conditions of the PatientCLARII HEALTH Medical Agreement Form. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □ Yearly (Credit/Debit Card) □ Monthly (Credit/Debit Card/Check) □ Employer _ *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in CLARII HEALTH Medical Agreement Form. I further certify that I have received a copy of this form. Signature: _ ure APPENDI3 X C FEE ITEMIZATION Monthly Membership Fee 18Direct Primary Care (DPC) 18 - 30 -59 years of age $ $24.95 200 per month 31$ 60+ years of age $ $49.95 275 per moFamily Discount (3+) 10% discount of monthly total Health Coaching $9.95 if added to DPC ($19.99 alone) Enrollment Fee* $99.00 Declined payment $25 per occurrence *Non-refundable fee. Should your membership lapse or be terminated, the registration fee must be paid again for membership to become active. Patient 1 nth $ Total Monthly Membership Patient 2 Additional Patients TOTAL RATE Fee $ Enrollment Fee $150 per MembAPPENDIX 4 MEDICARE OPT OUT AND WAIVER AGREEMENT This agreement er* (one Agreement) is entered into by and between Gateway Medical Practice d/b/a Clarii Healthtime, non-refundable) $ $250 per coua Maryland Limited Liability Company, Xx. Xxxxxxx X. Selaru (Physician), whose principal address is 0000 Xxx Xxxxxxxx Dr., Suite 206, Columbia, MD 21046, and , a beneficiary enrolled ple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental chargMedicare Part B es, pursuant to AppendiSection 4507 x C of ythe Balanced Budget Act of 1997 (Beneficiary), who resides at , , MD . The Physician has informed our Patient Agreement. You will receive a detailed statement priorthat Physician has opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Cardother section of the Social #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoAct.unt:

Specialists Coordination. The physician CLINIC and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientCLINIC Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(SPATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the following Patient(s), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient who by signing below agree to the terms and conditions of the VERITY PRIMARY MEDICINE & LIFESTYLE Medical Agreement Form. Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO Signature APPENDIX C FEE ITEMIZATMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □ Yearly (Credit/Debit Card/Bank Draft) □ ION Monthly Membership Fee 18-59 ye(Credit/Debit Card/Bank Draft) □ Employer *All patients must have a credit or debit card on file to cover the cost ars of age $ 200 per month $ 60+ yemembership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in VERITY PRIMARY MEDICINE & LIFESTYLE Medical Agreement Form. I further certify that I have received a copy ars of age $ 275 per month $ Total Monthly Membership Fee $ Enrollment Fee $150 per Member* (one time, non-refundable) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign this the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmSignatureount:

Specialists Coordination. The physician PRACTICE and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under understandsthatfeespaidunder this Agreement do not include Agreementdonotinclude anddo notcoverspecialist’sfees or cover specialist's fees or charges from any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patientfeesduetoanymedical professionalotherthanthe PRACTICE Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Monthly fees, as set out in Appendix C, SHALL APPLY TO THE FOLLOWING MEMBER(S)shall apply to the following Patient(s): Printed Name DateofBirth(MM/DD/YYYY) Age Street Address City, WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN)State, CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENTZip Home Phone Work Phone Cell Phone Preferred email Spouse Name DateofBirth(MM/DD/YYYY) Age Home Phone Work Phone Cell Phone Preferred email Child/Children to Whom this Agreement Applies: Patient 1 Print Patient Name Date of Birth Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienMM/DD/YYYY) Age Print t Name Date of Birth Cell Phone Home Phone Email Agre(MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □ Monthly (Credit/Debit Card/Bank Draft) □ Annually (Credit/Debit Card/Bank Draft/Check) *All patients must have a credit or debit card on file e to Text Communication: (check one below): 🞎 YES 🞎 NO Signatcover the cost of membership and any incidentals not covered under the Agreement. ure APPENDIX C FEE ITEMIZATION Monthly Membership Fe6e 1824 -59 years of age $ with a parent enrolled $39 per month* 18-24 years of age without a parent enrolled $49 200 per month 25-49 years of age $89 per month 50$ 60+ years of age $ 275 per month $ Total Monthly Membership Fe$109permonth e $ Enrollment Fee $150 per Me99*mbe*Patients under 18 require the enrollment of at least r* (one adult member. **Non-refundable fee. Should your membershiplapse or be terminatedtime, non-refundable) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit cenrollmentfee must be paid again ard for monthly fees and related incidental charges, pursumembership ant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amobecome active.unt:

Specialists Coordination. The physician MODERN MOBILE MEDICINE and its Physicians shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patienta MODERN MOBILE MEDICINE Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(SPATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the following Patient(s), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient who by signing below agree to the terms and conditions of the MODERN MOBILE MEDICINE Medical Agreement Form. Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print NamePreferred Payment Method* Date of Birth (MM/DD/YYYY) Age □ Yearly (Check Only) □ Monthly (Credit/Debit Card/Check) □ Employer *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in MODERN MOBILE MEDICINE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fe– FAMILY PREMIUM MEMBERSHIP Family $379/month Aftere 18-59 years of age $ 200 per month $ 60+ years of age $ 275 per month $ Total Monthly Membership Fehours/Weekend House Calls Surcharge $150/visit After-hours/Weekend Telemedicine Surcharge $40/consultation e $ Enrollment Fee $150 per Me199/familymbAdditional House Calls $100 off a la carte *Non-refundable fee. Should your membership lapse or be terminated, the enrollment fee must be paid again for membership to become active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ APPENDIX D MEDICARE OPT OUT AND WAIVER AGREEMENT This agreement er* (one Agreement) is entered into by and between Xxxxxxx Xxxxx MDtime, non-refundable) $ $250 per couPLLC d/b/a Modern Mobile Medicine, an Arizona Limited Liability Company, Xx. Xxxxxxx Xxxxx and Xx. Xxxxxxxxxx Xxxxx (collectively “Physicians”), whose principal address is 000 Xxxxxx Xxxxxx #545, Alexandria, Virginia 22305, and _ , a beneficiary enrolled ple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental chargMedicare Part B es, pursuant to AppendiSection 4507 x C of ythe Balanced Budget Act of 1997 (Beneficiary), who resides at _. The Physicians have informed our Patient Agreement. You will receive a detailed statement priorthat Physicians have opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Cardother section of the Social #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoAct.unt:

Specialists Coordination. The physician Clinic shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's specialists’ fees or charges from fees due to any medical professional other than the Practice staffPrimary Care Providers at the Clinic. Patients may submit such charges Appendix B Patient Enrollment – Medical Agreement Form Fees as set out below shall apply to their health care plan for reimbursement considerationthe following Patient(s) who, but we cannot guarantee reimbursement by signing below, agree to the terms and payment shall always remain the sole responsibility conditions of the PatientCEDAR VALLEY PRIMARY ACCESS Agreement Form. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient Name Date of Birth (MM/DD/YYYY) Age Street Address, City, State, Zip Home Phone Cell Phone Home Phone Email Agree Preferred E-mail Spouse/Child/Children to Text Communication: Whom this Agreement Applies (check one belowi.e., those enrolling for care): 🞎 Yes 🞎 No Signature: Patient 2 PatienSpouse’s t Name Date of Birt(MM/DD/YYYY) Age Spouse’s Home Phone Spouse’s h Cell Phone Home Phone Email AgreSpouse’s Preferred E-mail Child’s Name Date of Birth (MM/DD/YYYY) Age Child’s Name Date of Birth (MM/DD/YYYY) Age Child’s Name Date of Birth (MM/DD/YYYY) Age Child’s Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □ Yearly (Credit/Debit Card) □ Monthly (Credit/Debit Card) * All patients must have a credit or debit card on file e to Text Communicaticover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in CEDAR VALLEY PRIMARY ACCESS Medical Agree- ment Form. I further certify that I have received a copy of this form. SignatureonDate: Appendix C Fee Itemization Selection Monthly Cost Annual Cost Single $65 $780 Spouse/Partner $100 $1,200 Family : (check one below): 🞎 YES 🞎 NO Signature APPENDIX C FEE ITEMIZATION Monthly Members3 or more enrollees) $130 $1,560 Enrollment hip Fe$50 per account* Ree 18-59 years of age $ 200 per month $ 60+ years of age $ 275 per month $ Total Monthly Membership Fee $ Enrollmenrollment ent Fee $150 per Meaccount*mbOne-time Enrollment Costs: $ *Non-refundable fee. **Should your membership lapse or be terminated, the re-enrollment fee must be paid for membership to become active. Re-enrollment Fee er* (one time, non-refundIf ApplicableableProrate of Current Month $ Ongoing Monthly Cost ) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amount:

Specialists Coordination. The physician CLINIC and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientCLINIC Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(SPATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the following Patient(s), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient who by signing below agree to the terms and conditions of the MD4ME Medical Agreement Form. Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □ Yearly (Credit/Debit Card) □ Monthly (Credit/Debit Card) □ Employer *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in MD4ME Medical Agreement Form. I further certify that I have received a copy of this form. Signature: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18Individual (16+ -59 years of age $ old) $99 200 per month Individual + Dependent (16$ 60+ years of age $ old) $189 275 per month $ Total Monthly Membership FeEach Additional Dependent (16-18 years old) $89 per month e $ Enrollment Fee $99 150 per Mehouseholdmber* (one *Non-refundable fee. Should your membership lapse or be terminatedtime, non-refundabthe enrollment fee must be paid again for membership to become active. Patient 1 le) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amo2 Additional Patientsunt:

Specialists Coordination. The physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals to outside specialty care. The Patient understands that fees paid under this Agreement do not include or cover specialist's fees or charges from any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patient. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient Name Date of Birth Cell Phone Home Phone Email Agree to Text Communication: (check one below): ) 🞎 Yes 🞎 No Signature: Patient 2 Patient Name Date of Birth Cell Phone Home Phone Email Agree to Text Communication: (check one below)) : 🞎 YES 🞎 NO Signature APPENDIX C FEE ITEMIZATION Monthly Membership Fee39 years of age $ 125 per month $ 40- 18-59 years of age $ 175 200 per month $ 60+ years of age $ 250 275 per month $ Total Monthly Membership Fee $ Enrollment Fee $125 150 per Member* (one time, non-refundable) $ $225 250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal MediMedicine NOTICE OF PRIVACY PRACTICES This notice describes how health information about you may be used and disclosedcine, P.and how you can gain access C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amoyour individually identifiable health information.unt:

Specialists Coordination. The physician CLINIC and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientCLINIC Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(SPATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the following Patient(s), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient who by signing below agree to the terms and conditions of the VERITY PRIMARY MEDICINE & LIFESTYLE Medical Agreement Form. Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □ Yearly (Credit/Debit Card/Bank Draft) □ Monthly (Credit/Debit Card/Bank Draft) □ Employer *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in VERITY PRIMARY MEDICINE & LIFESTYLE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18Child (<21 -59 years of age $ old) $15 200 per month * Child (<21 years old) $55 per month** Individual (21-64 years old) $70 per month Individual (65$ 60+ years of age $ old) $80 275 per month $ Total Monthly Membership Fee $ Enrollment Couple (both 21-64 years old) $130 per month Couple (both 65+ tears old) Fee $150 per Memonth Couple (mixed age) $140 per month Registration Fee $75**mbeRe-enrollment fee $100**** *With the enrollment of at least r* (adult member. **Without a fully enrolled adult member. ***Registration fee is for Individuals or entire family if signing up at the same one . ****Non-refundable fee. Should your membership lapse or be terminatedtime,the re non-refundabenrollment fee must be paid for membership to become active. Patient 1 le) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amo2 Additional Patientsunt:

Specialists Coordination. The physician CLINIC and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staffCLINIC Physician. Patients may submit such charges APPENDIX 2 PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM DOCTOR DIRECT, LLC Annual fees as set out below shall apply to their health care plan for reimbursement considerationthe following Patient(s), but we cannot guarantee reimbursement who by signing below agree to the terms and payment shall always remain the sole responsibility conditions of the PatientDOCTOR DIRECT, LLC Medical Agreement Form. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient Printed Name Date of Birth Cell Phone Address Home Phone Email Agree Cell phone Email: Spouse Name DOB : Cell Phone: Email: Child/Children to Text CommunicationWhom this Agreement Applies: Print Name Print Name Print Name Print Name Preferred Payment Method* □ Yearly (check one below): 🞎 Yes 🞎 NCredit/Debit Card) □ Monthly (Credit/Debit Card/Check) □ *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. □ I authorize doctor direct to the full amount of any outstanding balance(monthly fees and ancillary charges ) on an ongoing scheduled monthly basis upon selected day while membership is active. □ I understand charges will continue to be accrued until a written cancellation of notice is given. □ I understand that doctor direct will notify me of nay failed payment attempts by email. I certify that I have read, understand, and agree to the terms set forth in DOCTOR DIRECT, LLC Medical Agreement Form. I further certify that I can request a copy of this form. o Signature: Patient 2 Patient Name Date of Birth Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 YES 🞎 NO Signature APPENDI3 X C FEE ITEMIZATION Monthly Membership Fe$15 per month* Ages 5e 18-59 years of age $ 19 $50 200 per month $ 60+ years of age $ Ages 20-49 $75 275 per month $ Total Monthly Membership Fee $ EnrollmAges 50-69 $85 per month Ages 70+ *With the enrollment of at least one adult. Without Adult $25 per month Re-enrollment ent Fee $100** **Non-refundable fee. May be adjusted 150 per Membphysician discretion. Should your membership lapse or be terminated, the re-enrollment fee must be paid in full prior to membership to becoming re- activated. After Hours Visit Fee er* (one at physician discretion) Home Call Visit Fee (at physician discretion) APPENDIX 4 MEDICARE OPT OUT AND WAIVER AGREEMENT This agreement (Agreement) is entered into by and between time, non-refundable) $ $250 per coua North Carolina Limited Liability Company, Dr. Xxx Xxxxx (Physician), whose principal address is 0000 Xxx Xxxxx Xxxx, Xxxxx 000, Xxxxxxx, Xxxxx Xxxxxxxx 00000, and , a beneficiary enrolled ple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental chargMedicare Part B es, pursuant to AppendiSection 4507 x C of ythe Balanced Budget Act of 1997 (Beneficiary), who resides at , , North Carolina . The Physician has informed our Patient Agreement. You will receive a detailed statement priorthat Physician has opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Cardother section of the Social #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoAct.unt:

Specialists Coordination. The physician CLINIC and Physicians shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientCLINIC Physicians. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX CPATIENT ENROLLMENT – MEDICAL AGREEMENT FORM ONSITEMD, SHALL APPLY TO THE FOLLOWING MEMBER(SLLC Annual fees as set out below shall apply to the following Patient(s), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN)who by signing below agree to the terms and conditions of the ONSITEMD, CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient LLC Medical Agreement Form. Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method*□ Yearly (Credit/Debit Card) □ Monthly (Credit/Debit Card/Check) □ Employer *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in ONSITEMD Medical Agreement Form. I further certify that I have received a copy of this form. Signature: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fe0e 1818 -59 years of age $ $39 200 per month 19-40 years of age $59 per month 41-64 years of age $79 per month 65$ 60+ years of age $ $99 275 per month $ Total Monthly Membership Fee $ EnrollmReenrollment ent Fee $150 per Me199mber* (one *Non-refundable fee. Should your membership lapsetime, non-refundabbe terminated, or cancelled within the first twelve months of membership, and you wish to reinstate your membership within twelve months of the lapse, termination, or cancellation, this fee must be paid for membership to become active. Patient 1 le) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amo2 Additional Patientsunt:

Specialists Coordination. The physician CLINIC and Provider shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientCLINIC Provider. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Monthly fees, as set out in Appendix C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient shall apply to the following Patient(s): Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □ Monthly (Credit/Debit Card/Bank Draft) □ Annually (Credit/Debit Card/Bank Draft) *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. SIGNATURE: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fe0e 1819 -59 years of age $ $25 200 per month $ month* 20-45 60+ years of age $ $60 275 per month $ Total Monthly Members46-65 years of age $75 per month Family (up to 2 adults, 2 children) $140 per month** Enrollment hip Fee $ Enrollm$75 per person, or $100 per family*** Reenrollment ent Fee $150 per Meperson, or $200 per family**mb*Each child must have one enrolled sponsoring adult. **$25 per month for each additional child, up to 19 years of age. ***Non-refundable fee. Should your membership lapse or be terminated, a reenrollment fee must be paid for membership to become active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ 1 as that term is defined in the Health Insurance Portability and Accountability Act er* (one time, non-refundHIPAAable) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION of 1996 and its implementing regulations. 2 As deemed appropriate and medically necessary by For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoProvider.unt:

Specialists Coordination. The physician MODERN MOBILE MEDICINE and its Physicians shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than a MODERN MOBILE MEDICINE Physician. FAMILY PREMIUM APPENDIX B PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the Practice staff. Patients may submit such charges following Patient(s), who by signing below agree to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement the terms and payment shall always remain the sole responsibility conditions of the PatientMODERN MOBILE MEDICINE Medical Agreement Form. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print NamePreferred Payment Method*□ Yearly (Check Only) Date of Birth (MM/DD/YYYY) Age □ Monthly (Credit/Debit Card/Check) □ Employer *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in MODERN MOBILE MEDICINE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18-59 years of age $ 200 – FAMILY PREMIUM MEMBERSHIP Family $399/per month $ 60+ years of age $ 275 per month $ Total Monthly Membership FeAfter-­‐hours/Weekend House Calls Surcharge $99/visit e $ Enrollment Fee $150 per Me199/familymbAdditional House Calls $50/each *Non-­‐refundable fee. Should your membership lapse or be terminated, the enrollment fee must be paid again for membership to become active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ APPENDIX D MEDICARE OPT OUT AND WAIVER AGREEMENT This agreement er* (one Agreement) is entered into by and between Xxxxxxx Xxxxx MDtime, non-refundable) $ $250 per couLLC d/b/a Modern Mobile Medicine, an Arizona Limited Liability Company, Xx. Xxxxxxx Xxxxx and Xx. Xxxxxxxxxx Xxxxx (collectively “Physicians”), whose principal address is 000 Xxxxxx Xxxxxx #545, Alexandria, Virginia 22305, and , a beneficiary enrolled ple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental chargMedicare Part B es, pursuant to AppendiSection 4507 x C of ythe Balanced Budget Act of 1997 (Beneficiary), who resides at . The Physicians have informed our Patient Agreement. You will receive a detailed statement priorthat Physicians have opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Cardother section of the Social #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoAct.unt:

Specialists Coordination. The physician PRACTICE and Physician shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the PatientPRACTICE Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Monthly fees, as set out in Appendix C, SHALL APPLY TO THE FOLLOWING MEMBER(S), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient shall apply to the following Patient(s): Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method (circle one)* Credit Card Debit Card Bank Draft *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in this Medical Agreement Form. Signature: _ ure APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18-59 years of age $ Per Patient $89 200 per month $ 60+ years of age $ 275 per month $ Total Monthly Membership Fee $ Enrollment F99 per person, up to $ee $150 per Mehouseholdmber* (one *Non-refundable fee. Should your membership lapse or be terminatedtime, non-refundabthe enrollment fee must be paid again for membership to become active. Patient 1 le) $ $250 per couple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental charges, pursuant to Appendix C of your Patient Agreement. You will receive a detailed statement prior to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring Amo2 Additional Patientsunt:

Specialists Coordination. The physician MODERN MOBILE MEDICINE and its Physicians shall coordinate Patient’s with the their medical specialists, and if requested, provide suitable referrals specialists to outside whom Patient is referred to assist Patient in obtaining specialty care. The Patient understands that fees paid under this Agreement do not include or and do not cover specialist's ’s fees or charges from fees due to any medical professional other than the Practice staff. Patients may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patienta MODERN MOBILE MEDICINE Physician. APPENDIX B Electronic Communications CHECK YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATION. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING MEMBER(SPATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Annual fees as set out below shall apply to the following Patient(s), WHO BY SIGNING BELOW (OR AS A LEGAL GUARDIAN), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT: Patient 1 Print Patient who by signing below agree to the terms and conditions of the MODERN MOBILE MEDICINE Medical Agreement Form. Printed Name Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Work Phone Cell Phone Home Phone Email Agree to Text Communication: (check one below): 🞎 Yes 🞎 No Signature: Patient 2 PatienPreferred email Spouse t Name Date of Birt(MM/DD/YYYY) Age Home Phone Work Phone h Cell Phone Home Phone Email AgrePreferred email Child/Children e to Text CommunicatiWhom this Agreement AppliesonPrint Name Date of Birth : (check one below): 🞎 YES 🞎 NO SignatMM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print Name Date of Birth (MM/DD/YYYY) Age Print NamePreferred Payment Method*□ Yearly (Check Only) Date of Birth (MM/DD/YYYY) Age □ Monthly (Credit/Debit Card/Check) □ Employer *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in MODERN MOBILE MEDICINE Medical Agreement Form. I further certify that I have received a copy of this form. Signature: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18-59 years of age $ 200 – STANDARD MEMBERSHIP Individual $79/per month $ 60+ years of age $ 275 per month $ Total Monthly Membership FeAfter-­‐hours/Weekend Telemedicine Surcharge $30/consultation After-­‐hours/Weekend House Calls Surcharge $200/visit e $ Enrollment Fee $150 per Me99/individualmbAdditional Telemedicine Consults $30/each Additional House Calls $99/each *Non-­‐refundable fee. Should your membership lapse or be terminated, the enrollment fee must be paid again for membership to become active. Patient 1 $ Patient 2 Additional Patients TOTAL RATE $ APPENDIX D MEDICARE OPT OUT AND WAIVER AGREEMENT This agreement er* (one Agreement) is entered into by and between Xxxxxxx Xxxxx MDtime, non-refundable) $ $250 per couLLC d/b/a Modern Mobile Medicine, an Arizona Limited Liability Company, Xx. Xxxxxxx Xxxxx and Xx. Xxxxxxxxxx Xxxxx (collectively “Physicians”), whose principal address is 000 Xxxxxx Xxxxxx #545, Alexandria, Virginia 22305, and , a beneficiary enrolled ple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental chargMedicare Part B es, pursuant to AppendiSection 4507 x C of ythe Balanced Budget Act of 1997 (Beneficiary), who resides at . The Physicians have informed our Patient Agreement. You will receive a detailed statement priorthat Physicians have opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Cardother section of the Social #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoAct.unt:

Specialists Coordination. The physician Physician shall coordinate with Patient’s with the their medical specialistsspecialists to assure continuity of care, and if requestednecessary, provide suitable referrals to outside shall assist in obtaining a referral for specialty care. The Patient understands that monthly fees paid under this Agreement do not include or cover specialist's ’s fees or charges from fees due to any outside medical professional other than professional. These are the Practice staff. Patients patient’s responsibility but Patient may submit such charges to their health care plan for reimbursement consideration, but we cannot guarantee reimbursement and payment shall always remain the sole responsibility of the Patientinsurance. APPENDIX B Electronic Communications CHECK PATIENT ENROLLMENT * Circle YES WHERE INDICATED ONLY IF YOU AGREE TO TEXT MESSAGE COMMUNICATIONwhere indicated only if you agree to text message communication and provide email address only if you agree to Email communication. PROVIDE EMAIL ADDRESS ONLY IF YOU AGREE TO EMAIL COMMUNICATION. THE FEES AS SET OUT IN THE ATTACHED APPENDIX The fees as set out in the attached Appendix C, SHALL APPLY TO THE FOLLOWING MEMBER(Sshall apply to the following Patient(s), WHO BY SIGNING BELOW who by signing below (OR AS A LEGAL GUARDIANor as parent or legal guardian), CERTIFY THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENTcertify that they have read and agree to the terms and conditions of this Agreement: Patient 1 Print Patient Name Date of Birth Street Address City, State, Zip Home Phone Cell Phone Home Phone Email Do you Agree to Text Communication: text message communication? YES NO (check one below): 🞎 Yes 🞎 NCircle one) o Signature: Patient Date 2 Patient Name Date of BirtHome Phone h Cell Phone Home Phone Email AgreDo you agree e to Text Communicatitext message communication? YES NO (Circle one) SignatureonDate Child/Children to Whom this Agreement Applies: Print Name Date of Birth : (check one below): MM/DD/YYYY) Print Name Date of Birth (MM/DD/YYYY) Print Name Date of Birth (MM/DD/YYYY) Do you agree to text message communication in regard to the above named children to and from the cell phone number written above or any other number provided to Us? 🞎 YES 🞎(Circle one) NO Signatparent or guardian _ Date _ RELATIONSHIP: ure APPENDIX C FEE ITEMIZATION Monthly Membership Fee 18Individual $ 75 per month Family Membership* $250 per month *2 Adults and 2 Dependents <26 -59 years of Non-refundable one-time enrollment fee age $ 200 per mo75. Individual $150 Family Patient 1 nth $ 60+ years of age $ 275 per moPatient 2 Additional Patients Enrollment Fees TOTAL AMOUNT DUE nth $ ToContinuing tal Monthly Membership Fee $ Enrollment Fee $150 per MembAppendix D Medicare Opt Out and Waiver Agreement This agreement er* (one Agreement) is entered into by and between Envision Health LLC time, non-refundable) $ $250 per couXxxxxxxx X. Xxx, DO(Provider), whose principal address is, 1501 S. Xxxxx Xxxxxx, Xxxxx 000, Xxxxx Xxxxx, Xxxxxxx 00000, and , a beneficiary enrolled ple in same household Total Enrollment Fee $ Initial Payment Total Monthly Membership Fee $ Total Enrollment Fee $ Total Initial Payment $ AUTOMATIC BILLING AUTHORIZATION For the convenience of automatic, reoccurring billing, simply complete the checking or debit/credit card information sections below and sign the form. Upon approval, we will automatically bill your checking account or debit/credit card for monthly fees and related incidental chargMedicare Part B es, pursuant to AppendiSection 4507 x C of ythe Balanced Budget Act of 1997 (“Beneficiary”), who resides at , . The Provider has informed our Patient Agreement. You will receive a detailed statement priorthat Provider has opted out of the Medicare program and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or to any payment deductions. Patient(s) Name(s): _ _ CHECK ONE: ____Checking Account Info: Name on Account: Bank Name: Account #: Routing #: ____Credit Card Info: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Cardother section of the Social #: Security Code: Expiration: / AUTHORIZATION I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified. Product/Service Description: Medical Services Recurring AmoAct.unt: