Authorized signature is on file. By signing, I attest that all information provided is true and correct. I authorize the release of any necessary medical information and payment of medical benefits to the physician for services rendered.

I understand and agree that:

1) I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read) and understood the notice.

2) I am responsible for all charges incurred including the balance remaining after payment of insurance benefits (as per your insurance contract); any third party billing such as labs or medical equipment etc. will become my responsibility

3) Payment is expected on the day services are rendered unless prior arrangements are made.

4) If we are unable to collect for services rendered, your account will be sent to a collection agency and all collection fees will be added to your balance.

** All co-pays are due at time of service.

You expressly consent and agree that, in order to discuss or service your accounts(s) (the “Accounts “) or to collect amounts you may owe, Fast Aid Urgent Care and its officers, agents, affiliates, employees, and any affiliated or associated service providers and any third-party debt collection agency associated therewith (collectively, “We”) may contact you by telephone at any telephone number associated with the Accounts, including wireless telephone numbers, which could result in charges to you. You expressly consent and agree that We may also contact you by sending text messages, emails, using any e-mail address you provide to us, or by pre-recorded or artificial voice or voice messages, automatic dialing methods, systems, or devices, and pre-recorded or artificial voice prompts at any telephone number associated with the Accounts, including wireless or mobile telephone numbers, regardless of whether you incur charges as a result.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. We call this information “protected health information” (PHI). We are required to protect the privacy of your PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. This notice describes how we may use and disclose your PHI and certain rights you have with respect to your PHI.

Uses and Disclosures for Treatment, Payment and Health Care Operations

HIPAA privacy rules permits us to use or disclose your PHI for the purposes of treatment, payment and health care operations, described in more detail below, without obtaining a specific written permission from you, known as an “authorization.”

FOR TREATMENT: We may use or disclose information (PHI) about you to coordinate your healthcare. We may consult with other health care providers who are involved in your health care. For example, information may be shared to create and carry out a plan for your treatment. FOR PAYMENT: We may use or disclose information to get payment for the health care services you receive. For example, we may provide PHI to bill your health plan for services provided to you.

FOR HEALTH CARE OPERATIONS: We may use or disclose information in performing business activities, which are called health care operations. Health care operations allow us to improve the quality of care we provide.

APPOINTMENTS AND OTHER HEALTH INFORMATION: We may send you reminders for medical services. We may send you information about health services that may be of interest to you.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object

We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. HIPAA Privacy Rule permits (or requires) us to use and disclose PHI without your written authorization under the circumstances described below: AS REQUIRED BY LAW AND FOR LAW ENFORCEMENT We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.

FOR ABUSE REPORTS AND INVESTIGATIONS: If we reasonably believe a patient has been a victim of abuse or neglect, we may disclose PHI as required by law.

FOR GOVERNMENT PROGRAMS: We may use and disclose information for public benefits under other government programs. For example, we may disclose information for the determination of Supplemental Security Income (SSI) benefits.

Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legallyestablished programs.

FOR RESEARCH: We may use information for studies and to develop reports.

DISCLOSURES TO FAMILY, FRIENDS AND OTHERS: We may disclose information to the family or others persons who are involved in the patient’s medical care. You have the right to object to the sharing of this information.

Your Privacy Rights:

RIGHT TO INSPECT AND COPY MEDICAL RECORDS: In most cases, you have the right to look at or get copies of your records. You must sign a medical release form. You may be charged a fee for the cost of copying your records as permitted by federal or state law.

RIGHT TO REQUEST RESTRICTIONS: This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.

RIGHT TO AMEND: You may ask us to change or add missing information to your records if you think there is a mistake. You must make the request in writing, and provide a reason for your request.

RIGHT TO RECEIVE CERTAIN DISCOSURES: You have the right to ask us for a list of disclosures made after April 14, 2003. You must make the request in writing. This list will not include the times that information was disclosed for treatment, payment or health care operations. This list will not include information provided directly to you or your family or information that was sent with your authorization.

RIGHT TO OBTAIN A PAPER COPY: You have the right to ask for a paper copy of this notice at any time.

RIGHT TO FILE A COMPLAINT: You have the right to file a complaint with us at the address listed below and with the Secretary of the United State Department of Health and Human Services if you do not agree about how we have used or disclosed information about you.

RIGHT TO REVOKE PERMISSION: If you are asked to sign an authorization to use or disclose information, you can cancel that authorization at any time. You must make the request in writing. This will not affect information that has already been shared.

RIGHT TO CHOOSE HOW WE COMMUNICATE WITH YOU: You have the right to ask that we share information with you in a certain way or in a certain place. For example, you can ask us to send information to your work address instead of your home address. You must make this request in writing. You do not have to explain the reason for your request.

RIGHT TO RECEIVE NOTICE OF CHANGE TO FAST AID URGENT CARE PRIVACY STATEMENT: You have a right to receive notice of changes in our privacy statement that affect you on or after the effective date of the change.

If you have any questions about this Notice, the name and phone number of our contact person is listed on this page.

Please list below who you would like us to share your PHI in the event you are unable to do so, and your relationship with them. We will not release any PHI unless person name is on the list below.

For other situations, we will ask for your written authorization before using or disclosing information. You may cancel this authorization at any time in writing. We cannot take back any uses or disclosure already made with your authorization.

I hereby acknowledge that I have received a copy of this practice’s NOTICE OF PRIVACY PRACTICES. I understand that if I have questions or complaints regarding my privacy rights that I may contact the person listed above. I further understand that they practice will offer me updates to this NOTICE OF PRIVACY PRACTICES should it be amended, modified or changed in any way.