Date of birth

Complete Address

I hereby give my consent for WNY House Physician, PLLC to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by WNY House Physician, PLLC describes such uses and disclosures more completely. I have the right to review the Notice of Privacy Practices prior to signing this consent. WNY House Physician, PLLC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to:

Facility: WNY House Physician, PLLC

60 Brynstone CT

Amherst, NY 14228

United States

Phone: 716-474-5983

Fax: 716-580-3444

Email:contact@wnyhousephysician.com

With this consent, WNY House Physician, PLLC may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others. With this consent, WNY House Physician, PLLC may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential”. With this consent, WNY House Physician, PLLC may e-mail to me or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to allow WNY House Physician, PLLC to use and disclose my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, WNY House Physician, PLLC may decline to provide treatment to me.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by our organization, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the organization, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for equipment or supplies coverage may require that your relevant protected health information be disclosed to the health plan to obtain approval for coverage. Healthcare Operations: We may use or disclose, as‐needed, your protected health information in order to support the business activities of our organization. These activities include, but are not limited to, quality assessment activities, employee review activities, accreditation activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to accrediting agencies as part of an accreditation survey. We may also call you by name while you are at our facility. We may use or disclose your protected health information, as necessary, to contact you to check the status of your equipment. We may use or disclose your protected health information in the following situations without your authorization: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Criminal Activity, Inmates, Military Activity, National Security, and Workers’ Compensation. Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. Other Permitted and Required Uses and Disclosures Will Be Made Only with Your Consent, Authorization or Opportunity to Object, unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or this organization has taken an action in reliance on the use or disclosure indicated in the authorization. Your Rights: Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. 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 healthcare 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. Your request must state the specific restriction requested and to whom you want the restriction to apply. Our organization is not required to agree to a restriction that you may request. If our organization believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, e.g., electronically. You may have the right to have our organization amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information, if you have any questions concerning or objections to this form, please ask to speak with us at 716-474-5983. Associated companies with whom we may do business, such as an answering service or delivery service, are given only enough information to provide the necessary service to you. No medical information is provided. We welcome your comments: Please feel free to call us if you have any questions about how we protect your privacy. Our goal is always to provide you with the highest quality service.

I request and authorize medical care as my physician, his assistant or designees (collectively called “the providers”) may deem necessary or advisable. This care may include, but is not limited to, routine diagnostics, radiology and laboratory procedures, administration of routine drugs, biological and other therapeutics, and routine medical and nursing care. I authorize my provider(s) to perform other additional or extended services in emergency situations if it may be necessary or advisable in order to preserve my life or health. I understand that my (the patient) care is directed by my provider(s) and that other personnel render care and services to me (the patient) according to the provider(s) instructions. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees or promises have been made to me with respect to results of such diagnostic procedure or treatment. I understand that samples of body fluids and/or tissues may be withdrawn from me (the patient) during routine diagnostic procedures. I authorize WNY HOUSE PHYSICIAN, PLLC to dispose of the bodily fluids. I have been informed and understand that an HIV (human immunodeficiency virus – AIDS) test may be performed on me without my consent if a health professional or WNY HOUSE PHYSICIAN, PLLC employee or First Responder sustains an exposure to my blood or other body fluid. HIV testing/screening may be performed with verbal explanation and consent. WNY HOUSE PHYSICIAN, PLLC does not offer anonymous testing. If you request an anonymous HIV test, then WNY HOUSE PHYSICIAN, PLLC can assist you in locating a facility which does such. You have the right to withdraw your consent for the test at any time before the test is complete. You have the right to ask questions and have them answered prior to the test and after results are reported. Screening for Hepatitis or other infectious diseases may also be performed with a verbal consent. WNY HOUSE PHYSICIAN, PLLC will report all positive test results to the Department of Health or other agency, as determined by state and local regulations. A drug screen by blood or urine sample may be obtained with verbal consent for purposes of verifying compliance with medication regimens or when abuse or misuse is suspected or when signs or symptoms of toxicity exist.

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

WNY HOUSE PHYSICIAN, PLLC Notice of Privacy Practices provides information about how protected health information about me (the patient) – including information about human immunodeficiency virus (HIV), AIDS-related complex (ATC) and acquired immunodeficiency (AIDS); including substance abuse treatment records protected under the regulation 42 Part 2, in the Code of Federal Regulations (if any); and psychological and social services records, including communication made to me to a social worker or psychologist (if any) may be disclosed. I have been offered an opportunity to review the Notice before signing this consent. I understand that the terms of the Notice may change and I may obtain a revised copy by contacting WNY HOUSE PHYSICIAN, PLLC. I understand that I have the right to request restrictions on how my protected health information is used or disclosed for treatment, payment or healthcare operations. My physician(s) and WNY HOUSE PHYSICIAN, PLLC are not required to agree to this restriction, but if they agree, will be bound by the agreement. By signing this form, I acknowledge that I have been offered and/or received the WNY HOUSE PHYSICIAN, PLLC General Consent for Treatment.

ASSIGNMENT OF INSURANCE BENEFITS

Medicare Certification: I certify that the information provided by me in applying for payment under TITLE XVII of the Social Security Act is correct and request on my behalf all authorized benefits. I hereby authorize and instruct my insurance carrier to make payment directly to WNY HOUSE PHYSICIAN, PLLC for benefits (payments) otherwise payable to me. I agree to personally pay for any charges that are not covered by or collected from any insurance program, including any deductibles and coinsurance amounts.

AUTHORIZATION TO RELEASE HEALTH INFORMATION

I understand that as part of my healthcare, WNY HOUSE PHYSICIAN, PLLC, originates, maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that my medication history and formulary benefits may be downloaded from a secure electronic clearinghouse. I understand that this information serves as: A basis for planning my care and treatment , A means of communication among the many health professionals who contribute to my care, A source of information for applying my diagnosis and surgical information to my bill, A means by which a third-party payer can verify that services billed were actually provided, A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals I acknowledge that a copy of Notice of Privacy Practices was provided to me.I understand that I have the following rights and privileges:

• The right to review the notice prior to signing this consent

• The right to object to the use of my health information for directory purposes.

• The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations.

I understand that WNY HOUSE PHYSICIAN, PLLC is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations. I further understand that WNY HOUSE PHYSICIAN, PLLC reserves the right to change its notice and practices, in accordance with Section 164.520 of the Code of Federal Regulation. Should WNY HOUSE PHYSICIAN, PLLC change its notice, it will send a copy of any revised notice to the address I have provided (whether U.S. mail or, if I agree, via email). I HAVE READ OR HAD READ TO ME AND FULLY UNDERSTAND THIS CONSENT; I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND HAD THESE QUESTIONS ADDRESSED.understand that as part of this organization’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax. I understand and acknowledged that I received a Notice of Privacy Practices, and I consent to such disclosures as delineated in the Notice. I understand that this may include information relating to: (check and initial if applicable)

• Acquired immunodeficiency syndrome (AIDS)

• Human immunodeficiency virus (HIV)

• Treatment for alcohol and/or drug abuse

• Behavioral health service/psychiatric care

CANCELLATION POLICY

• If an appointment is cancelled at least 24 hours before, there are no charges.

• If an appointment is cancelled within 24 hours of scheduled appointment, there will be a same day cancellation fee of $200.00.

• If you have confirmed an appointment and you don't respond to our phone call on the day of the appointment, we will not come to your house, and you will have to pay $200.00, for no show.

Full Name of Patient/Parent/Guardian or Authorized Representative

Date

Signature of Patient/Guardian