CONSENT FOR TREATMENT/MEDICAL RELEASE AND DISCLOSURE AUTHORIZATION

I, the undersigned, hereby authorize ABOVE URGENT CARE and whoever they designate as their assistants to perform diagnostic tests, including but not limited to radiographs, and administer treatment as is necessary. I also certify that no guarantee or assurance has been made to the results that may be obtained. I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid to his account. I CLEARLY UNDERSTAND AND AGREE THAT ALL SERVICES RENDERED TO ME ARE CHARGED DIRECTLY TO ME AND THAT I AM PERSONALLY RESPONSIBLE FOR PAYMENT. I UNDERSTAND THAT ABOVE URGENT CARE WILL VERIFY INSURANCE COVERAGE BUT THIS IS NOT A GUARANTEE OF PAYMENT OR HOW MY INSURANCE COMPANY WILL PROCESS MY TYPE OF INSURANCE COVERAGE I HAVE.

REQUEST FOR PAYMENT OF BENEFITS TO PROVIDER OF CARE

I hereby authorize my primary/secondary insurance company admin to pay by check, and for it to be mailed directly to ABOVE URGENT CARE the expense benefits allowable and otherwise payable to me under my current policy, as payment toward the total charges for professional services rendered. I have agreed to pay, in a current manner, any balance of said applicable charges. I agree that this office be given power of attorney to endorse/sign my name on all drafts for payment of my bill.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I authorize the release of any medical information necessary to process my insurance claim and certify that all insurance information given to ABOVE URGENT CARE is correct and complete.

CONSENT FOR TREATMENT OF MINOR

I hereby authorize ABOVE URGENT CARE and whomever they may designate as their assistant to perform diagnostic test, including but not limited to radiographs, and to administer treatment as he deems necessary to my child.

SELF PAY / NO INSURANCE FINANCIAL POLICY

Office Visit - Consultation fee does not include treatment. Treatment / In Office Procedures - Any type of order that is requested by the Physician is rendered at an additional fee and must be paid in full at the time of service. Examples of this (but not limited to) would be X-RAYS, THERAPEUTIC INJECTION (ANTIBIOTIC), URINALYSIS, SUTURES, LABS OR SPLINTS. (*this service is NOT included in routine medical visit fees - this is considered an "in-office" procedure and will be billed accordingly.) Patients will be held completely responsible for all accrued charges and account balances regarding all services rendered by ABOVE URGENT CARE.

X RAY/MEDICAL RECORDS RELEASE

I hereby request and authorize you, your employees and agents to furnish to the person listed below or anyone designated in writing by them.2 copies of records including copies of x-rays and photostatic copies, abstracts or excerpts of all records and any other information they may request relating to any examination treatment or opinion concerning any condition that I may have in the past, now have, or may have in the future. Please forward this to ABOVE URGENT CARE 8891 N CENTRAL AVE SUITE A, MONTCLAIR, CA 91763

ATTORNEY REPRESENTATION AND PROTECTION OF BALANCE

I, the undersigned patient, am directing my attorney to pay any outstanding bills of my settlement and, in effect, protecting any such balance. I hereby make and declare the instructions herein to be irrevocable. I fully understand that I am directly responsible for all medical bills and this agreement is made solely for the doctor's additional protection and consideration of his awaiting payment. I further understand that such payment is not contingent on any settlement, judge or verdict by which I may eventually recover said fee. I have been advised that if my attorney does not wish to cooperate in protecting the doctor's interest, the doctor will not await payment but will require me to make payment on a current status.

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION (PHI)

By signing this Authorization, I hereby authorize ABOVE URGENT CARE and its affiliates (PROVIDER) to receive and release my protected health information (PHI) as part of my treatment, payment, and health care activities including care coordination to all my providers at my Accountable Care Organization (ACO), Managed Care Organization (MCO), or other care coordination programs and my past, current, and future treating providers (each a "Recipient"). In addition, I hereby authorize PROVIDER to receive AND release the following information from my health record to/from the following Recipient: AGNO HEALTH, INC. (888) 658-8224, hello@agnohealth.com. Specific Information to be disclosed: Entire Medical Record including patient histories, office notes (except psychotherapy notes), test results, referrals, consults, billing records, insurance records, and records received from other health care providers. By initialing below, I specifically authorize the release of the following information from my health record: Mental Health Records (Other than psychotherapy notes) This Authorization will remain in effect until one year from the date of signature.

I have read this form and I understand and agree to its terms. I direct ABOVE URGENT CARE to use or to disclose the information to the noted Recipient as directed above. I understand that once my information is disclosed, it could be re-disclosed by the Recipient and may no longer be protected by privacy laws, including the federal Health Insurance Portability and Accountability Act of 1996. I understand that I may revoke this Authorization in writing at any time, except that the revocation will not have any effect on any action taken by PROVIDER in reliance on the Authorization before written notice of revocation is received by PROVIDER. I further understand that I must provide any notice of revocation in writing to the Privacy Officer at ABOVE URGENT CARE, 8891 N Central Avenue, Suite A Montclair, CA 91763. I have carefully read and understand the terms of this Authorization. I have had the opportunity to ask questions about the use and disclosure of my health information by my signature below. I hereby knowingly and voluntarily, authorize the disclosure of the above protected health information to the designated entity as specified above. I give my permission to share my protected health information, which may include protected or privileged information, in written and/or another stored format.

Acknowledgement of Receipt of Notice of Privacy Practices

I certify that I am aware of Notice of Privacy Practices. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment of my bills or in the performance of Above Urgent Care health care operations. The Notice of Privacy Practices also describes my rights and Above Urgent Care's duties with respect to my protected health information. The Notice of Privacy Practices is posted at 8891 N Central Ave. Ste A, Montclair CA. 91763.  Above Urgent Care reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain the notice or a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail, asking for one at the time of my next appointment.

The person served and/or personal representative must be provided with a copy of the signed Authorization.