PainPA, LLC

PLEASE REVIEW THE POLICIES OR AGREEMENTS AND ENTER YOUR NAME THE BOX BELOW AS EVIDENCE OF OUR AGREEMENT

HIPAA POLICIES PATIENT OR INSURED'S OR AUTHORIZED PERSON'S CONSENTS: I understand that in the course of providing care to me DR. ZAHL, d/b/a PAINPA, LLC (the Practice) will receive, create, maintain and disclose information about me for the purpose of the Practice's and other REFERRED health provider's provision of treatment, securing payment from me, an insurer, other third-party payer or responsible party, and/or in connection with the health care operations of the Practice and/or the operations other health providers who have treated me and as otherwise required or permitted by State and/or Federal Law. I understand that a further description of these anticipated uses and disclosures of my health information appears in the Practice's Notice of Privacy Practices. Except for genetic information, I agree to the sharing, utilization, examination and disclosure of any of my health information, including but not limited to known or suspected HIV/AIDS infection, mental health records, communicable diseases, substance abuse and/or treatment, if applicable, as is reasonably necessary by the Practice, its employees and other members of its workforce for the limited purpose of rendering treatment, securing payment for treatment rendered and conducting the Practice's operations. I further agree to the disclosure by the Practice of such information, as is reasonably necessary, to other health providers involved in my treatment and their employees and other members of their workforce for treatment, payment and health operations, to any private or governmental insurer, including Medicaid and Medicare and its intermediaries and agents, other third-party payers, or other financially responsible party for the purpose of determining benefits and securing payment, and as otherwise permitted by State and/or Federal law.This consent may be revoked at any time but, only to the extent that the Practice has not acted in reliance on it. If not previously revoked, this consent will remain valid as long as I am a patient of the Practice and for such period of time thereafter as is reasonably necessary to serve the purpose for which it was given; namely, the provision of treatment, securing payment for services rendered and conducting health operation.

TELEMEDICINE CONSENT Telemedicine involves the use of electronic communications to enable physicians or facilities or the patient at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/ or education, and may include any of the following: ? Patient medical records Medical images ? Live two-way audio and video ? Output data from medical devices and sound and video files Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. EXPECTED BENEFITS ? Lower Risk of Infection Improved access to medical care by enabling a patient to remain in his/her home (or at a remote site) while the physician does the evaluation, or obtains test results and consults from healthcare practitioners at distant/other sites. ? More efficient medical evaluation and management. ? Obtaining expertise of a distant specialist. POSSIBLE RISKS As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to: ? In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s); ? Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment; ? In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information; ? In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reaction or other judgment error. NON-DISCLOSURE-AGREEMENT You have requested that Dr. Zahl, PainPA, LLC (or the Practice) to accept (or continue with) you as its patient to provide medical care - and other related services - to treat your pain condition, serious medical or chronic opioid dependence condition (as applicable).Given that your potential, or current treatment is highly complex and subject to confidentiality, you are making the promises and agreements set forth below in order for the Practice to accept you, or continue to treat you as a patient, as applicable.For example your potential or current treatment is highly regulated by the US Drug Enforcement Administration (DEA), the Pennsylvania (PA) State Board of Medicine, PA Department of Health (DOH), PA Board of Pharmacy, and other potential parties such as Medicare or other insurance carrier. In addition Dr. Zahl, in order to treat your condition, must also comply with many legal requirements in addition to the standard of care. There is another layer of Federal laws for PainPA, LLC to comply with from the U.S. Department of Health and Human Services (HSS), which is commonly know as HIPPA This law, called the Health Insurance Portability and Accountability Act of 1996 (HIPAA), gives you rights over your health information, including the right to get a copy of your information, make sure it is correct, and know who has seen it. The Privacy Rule, is a Federal law, gives patients rights over health information and sets rules and limits on who can look at and receive health information. The Privacy Rule applies to all forms of individuals' protected health information, whether electronic, written, or oral.Generally, your health information cannot be used for purposes not directly related to your care without your permission. For example, a doctor cannot give it to your employer, or share it for things like marketing and advertising, without your written authorization (see www.hhs.gov/ocr/privacy/). In our country, freedom of speech and expression is strongly protected from government restrictions by the First Amendment to the United States Constitution, many state constitutions, and at times state and federal laws. At times there have disagreements over your potential or current treatment and patients have decided to write or post negative comments about Dr. Zahl or PainPA, LLC's staff. Defamation laws protect people and companies from untrue, damaging statements. They provide important recourse for people whose careers, reputations, and/or finances have been damaged by the harmful statements. Libel and slander are terms which fall under the umbrella of defamation. Libel is written defamation, and slander is spoken defamation Written defamation about a medical doctor can be published in a paper, magazine; or nowadays more frequently on the internet such as on Facebook, Google, vitals.com, ucomphealth.com etc. On these internet sites there is no newspaper editor to fact-check harmful statements, and ask for a rebuttal before the harmful statement is published. Due to HIPPA laws PainPA or Dr. Zahl cannot respond to defamatory comments without further revealing private and confidential information about you, which places him and the practice at a disadvantage. It is the practice's decision thus to use this NON-DISCLOSURE AGREEMENT to limit potential defamatory actions or libel.You are making the promises and agreements as set forth below in order to have PainPA, LLC to accept, or continue to treat you, as a patient as applicable Those promises and agreements are part of what the Practice is receiving in exchange for agreeing to treat you and to permit you to receive all or a portion of the subject patient care services, and as such the Practice is relying on your fulfillment of these promises and. agreements.Any initially capitalized items that are not defined when used in this agreement are defined in paragraph 3 below. 1. Willful Disclosure of Confidential Information. during the term of your treatment and at all times thereafter you hereby promise and agree: a. not to disclose, disseminate or publish, or cause to be disclosed, disseminated. or published, any Confidential Information; b.not to assist others in obtaining, disclosing, disseminating, or publishing Confidential Information; c. not to use any Confidential Information in any way detrimental to the Practice, Dr. Zahl, or its Employees.2. Disparagement. During the term of your treatment and at all times thereafter you hereby promise and agree not to demean or disparage publicly the Practice, Dr. Zahl, or its Employees 3. Definitions. As used in this agreement, the following definitions apply: a. "Confidential Information" means all information related to your treatment < b. "Employee" means any employee of Dr. Zahl, or PainPA, LLC. c. "Practice" means the medical practice company (PainPA, LLC) owned by Kenneth Zahl, MD. 4. Remedies for Breach of this Agreement. a. Consent to Injunction. A breach of any of your promises or agreements under this agreement will cause the Practice, Dr. Zahl, and Employees irreparable harm. Accordingly, to the extent permitted by law, and without waiving any other rights or remedies against you at law or in equity, you hereby consent to the entry of any order, without prior notice to you, temporarily or permanently enjoining you from violating any of the terms, covenants, agreements or provisions of this agreement on your part to be performed or observed. Such consent is intended to apply to an injunction of any breach or threatened breach. b. Agreement to Indemnify. You hereby agree to indemnify, and hold harmless each Employee from and against any claim, demand, suit, proceeding, damages, cost, loss or expense of any kind or nature, including but not limited to reasonable attorneys' fees and disbursements, incurred by the Practice as a consequence of your breach of any of your promises or agreements in this agreement. c. Damages and Other Remedies. Notwithstanding anything to the contrary, the Practice will be entitled to all remedies available at law and equity, including but not limited to monetary damages, in the event of your breach of this agreement. Nothing contained in this agreement will constitute a waiver of any Practice remedies at law or in equity, all of which are expressly reserved. 5. Resolution of Disputes. a. Governing Law: Jurisdiction and Venue. This Agreement is deemed to have been made in the State of Pennsylvania and any and all performance hereunder, breach hereof, or claims with respect to the enforceability of this agreement must be interpreted and construed pursuant to the laws of the State of Pennsylvania without regard to conflict of laws or rules applied in the State of Pennsylvania. You hereby consent to exclusive personal jurisdiction and venue in the State of Pennsylvania with respect to any action or proceeding brought with respect to this agreement. b. Arbitration. Without limiting the Practice's or any Employee's right to commence a lawsuit in a court of competent jurisdiction in the State of Pennsylvania, any dispute arising under or relating to this agreement may, at the sole discretion of the Practice or its Employees, be submitted to binding arbitration in the State of Pennsylvania pursuant to the rules for commercial arbitrations of the American Arbitration Association, and you hereby agree to and will not contest such submissions. Judgment upon the award rendered by an arbitrator may be entered in any court having jurisdiction. c. Prevailing Party Fees. Any court judgment or arbitration award shall include an award of reasonable legal fees and costs to the prevailing party. d. Interpretation and Representation by Counsel. This agreement has been drafted on behalf of the undersigned only as a convenience and may not, by reason of such action, be construed against the undersigned. Each of the parties (i) has had the opportunity to be and/or has elected not to be, represented by counsel, (ii) has reviewed each of the provisions in this agreement carefully and (iii) has negotiated or has had full opportunity to negotiate the terms of this agreement, specifically including, but not limited to Paragraph 7 hereof. You waive any claims that may be available at law or in equity to the effect that you did not have the opportunity to so consult with counsel. e. No Waiver. Neither the failure or delay to exercise one or more rights under this agreement nor the partial exercise of any such right, will be deemed a renunciation or wavier of such rights or any part thereof or affect, in any way, this agreement or any part hereof or the right to exercise or further exercise any right under this agreement or at law or in equity.6. Miscellaneous. a. Modifications. No change or waiver of the terms, covenants and provisions of this agreement will be valid unless made in writing and signed by the undersigned. b. Relationship. Nothing herein contained is intended to, nor shall it be construed as, reflecting any doctor-patient relationship between you and the undersigned or any other individual or entity. c. Counterparts. This agreement may be executed in any number of counterparts, all of which taken together will constitute one and same instrument. d. Delivery of an executed signature page of this agreement by facsimile transmission or .pdf, .jpeg, .TIFF, or other electronic format or electronic mail attachment will be effective as delivery of an original executed counter party hereof7. Survival. This agreement will survive the expiration, cancellation or termination of any doctor-patient relationship that you may have with the Practice or with any individual, entity, partnership, or trust organization that the Practice has engaged.

BILLING POLICIESIf applicable, as is reasonably necessary by the Practice, its employees and other members of its workforce for the limited purpose of rendering treatment, securing payment for treatment rendered and conducting the Practice's operations. I further agree to the disclosure by the Practice of such information, as is reasonably necessary, to other health providers involved in my treatment and their employees and other members of their workforce for treatment, payment and health operations, to any private or governmental insurer, including Medicaid and Medicare and its intermediaries and agents, other third-party payers, or other financially responsible party for the purpose of determining benefits and securing payment, and as otherwise permitted by State and/or Federal law. This consent may be revoked at any time but, only to the extent that the Practice has not acted in reliance on it. If not previously revoked, this consent will remain valid as long as I am a patient of the Practice and for such period of time thereafter as is reasonably necessary to serve the purpose for which it was given; namely, the provision of treatment, securing payment for services rendered and conducting health operation BILLING POLICIES I expressly agree and acknowledge that my signature on this document authorized Kenneth Zahl, MD, or their employees to submit claims for services rendered without obtaining my signature on each and every claim to be submitted for myself and/or dependents and that I will be bound by this signature as though the undersigned had personally signed the particular claim. I am aware that for either practice to bill to my insurance carrier on my behalf is a courtesy being extended to me, and is NOT required by law. I further agree and fully understand that I am legally bound to furnish the checks paid to me by my carrier for the services I am receiving at this office. I also agree and fully understand that as a non participating physician, Dr. Zahl is not bound or legally obligated to accept the payment from my insurance company as payment in full for the services I am receiving, and I will receive a balance bill for the amounts not paid by my carrier. I hereby authorize the above named insurance company/companies to assign directly all benefits payable. I make this an irrevocable assignment of benefits. I understand that any insurance checks issued belong to Kenneth Zahl, MD for services rendered and I agree to endorse them over should I receive them or otherwise repay any amounts paid to me. Failure to do so would be a crime under PENNA law. (Theft by failure to make required disposition of funds received - 18 Pa. Cons. Stat. 3927 and/or Theft of services - 18 Pa. Cons. Stat. 3926) or other neighboring state laws (E.G. NJ & NY). I(we) am (are) aware that if payment is not made within a reasonable amount of time by the insurance carrier(s), or myself (ourselves) that the matter is submitted to a collection agency/attorney, I (we) will be responsible for payment of all collection fees and costs. Once the account is being past due the Practice reserves the right to begin adding interest at 1% per month simple interest, and if sent to collection, I (we) will be responsible for costs for collection agents and/or reasonable attorneys fees and/or costs of litigation and post judgment interest. Any outstanding balance after 90 days of the date of service may be referred to an outside collection agency. Accounts referred to an outside collection agency will be subject to a collection fee of 33%, which will be added to the total balance due at the time of referral to collections. I expressly authorize this provision, by electronically sending this form.

HIPAA ADDITIONAL CLAUSEExcept for genetic information, I agree to the sharing, utilization, examination and disclosure of any of my health information, including but not limited to known or suspected HIV/AIDS infection, mental health records, communicable diseases, substance abuse and/or treatment.

THIS IS THE WHOLE BILLING AGREEMENT, NON-DISCLOSURE AGREEMENT, HIPPA & TELEMEDICINE CONSENTS WHICH CANNOT BE CHANGED ORALLY, IF CHANGED, IT CAN ONLY BE DONE BY MUTUAL CONSENT IN WRITING. BY ENTERING MY NAME BELOW I ATTEST THAT I UNDERSTAND THE ABOVE TO MY FULL SATISFACTION, AND I AGREE THAT ENTERING MY NAME BELOW ONLINE, BINDS ME AS A FULL LEGAL SIGNATURE.

ELECTRONIC SIGNATURE: * PHONE NUMBER: * DATE OF BIRTH * OTHERS ALLOWED TO RECEIVE INFORMATION *

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