PRIME CARE PHYSICIANS NEW PATIENT REGISTRATION FORM

First Name * Last Name * Email * Confirm email * Date of Birth * Gender * Who This Visit is For * ...other Home Address * City * Current State You Are Physically In * Zip code * Preferred Form of Contact * Phone Number * Social Security Number * Occupation * Employer Name & Phone Number * Marital Status * Name of Spouse (or parents if minor) How did you hear about us? *

SPOUSE (OR PARENT/GUARDIAN) INFORMATION

Name * DOB * Employer * Employers Address/Phone Number *

PAYMENT INFORMATION

*Payment is expected at the time of your visit for deductibles, co-payments, and unpaid insurance balances.

PRIMARY INSURANCE

Name of Insurance Company * Policy Holder Name * Policy Number/Group Number * DOB * Relationship to Patient *

SECONDARY INSURANCE

Name of Insurance Company * Policy Holder Name * Policy Number/ Group Number * DOB * Relationship to Patient *

YOUR PREFERRED PHARMACY

Name of Pharmacy * Address or Location (Cross Streets) * Telephone * Fax Number

PATIENT HISTORY

What would you like to discuss today? * other: Have you ever been diagnosed with any of the following conditions? * Are you allergic to any of the following medications? * Are you currently taking any medications? * List the names of any medications you are currently taking * Please list any medications you are taking, including over-the-counter. * Supplements: * Have you ever had an allergic reaction to any medication? * Name of medication(s) you are allergic to: *

HOW RECENTLY HAVE YOU HAD THE FOLLOWING EXAMS

Blood Pressure * Cholesterol Check * Dental Exam * Eye Exam * Last Colonoscopy * Prostate Exam * Rectal/ stool * Breast Exam * Mammogram * Pap Smear * ANY SURGERIES OR PROCEDURES? PLEASE SELECT *

Family Medical History. Please indicate if the following medical issues have affected your family. (Specify relationship to individual)

Bleeding Disorder Cancer Diabetes Heart Disease Hypertension Stroke Heart Attack Other, please specify Do you smoke? * Do you drink? * Do you use recreational drugs? * Do you exercise on a regular basis? *

Terms of Use & Notice of Privacy Practices

Patient Privacy, Office Policy, and Assignment of Rights and Benefits

HIPAA NOTICE OF PRIVACY PRACTICES:This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. 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 your physician, 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 physician's practice, 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 a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment We may use or disclose your protected health information in the following situations without your authorization. These situations include: 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: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers' Compensation: Inmates: 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 Use 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 the physician's practice has taken on 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. Your physician is not required to agree to a restriction that you may request. If physician 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 i.e. electronically. You may have the right to have your physician 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. This notice was published, and becomes effective on/or before April 14, 2003. 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 objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number. Signature below is only acknowledgement that you have received this Notice of our Privacy Practices.

AUTHORIZATION FOR EVALUATION AND TREATMENT: I hereby authorize Matian Medical Corp., its affiliates, physicians, employees, and designated agents, to perform a physical examination and/or any medical treatment deemed necessary by the physician(s). These may include, without limitation, any required examination, medical, diagnostic or laboratory tests and medical procedures ordered by the physician(s) to be performed by the designated Matian Medical Corp. staff. I understand that certain special medical exams such as annual, executive, fitness for duty, school/sports physical exams, and other similar services are not intended for purposes of medical diagnosis and/or treatment, or to replace the medical care of my personal physician.

CONSENT FOR NON-REGULATED SUBSTANCE ABUSE TESTING: When applicable, I voluntarily authorize Matian Medical Corp. to obtain a specimen of my urine, blood, saliva, breath, hair and/or other specimen, to determine the presence of drugs and/or alcohol, and subsequent release of the results to my employer/prospective employer, or another designated party.

APPOINTMENTS:It is important that you arrive on time for your appointment. The office may need to reschedule me if I arrive more than 10 minutes past my appointment time. For legal reasons all patients under the age of 18 must be accompanied by an adult at all appointments, unless proper consent arrangements have been made with the doctor. All patients are required to go through our cycle of service. This starts on the first visit with a new patient well exam. A follow-up appointment will be made for any specific problems. If I need to reschedule or cancel my appointment I will give at least 24-hour advance notice. Matian Medical Corp. reserves the right to assess a $50.00 charge for missed appointments.

PERSONAL INJURY, LITIGATED WORKMANS' COMPENSATION, AND OTHER LIEN CASES:I do hereby authorize Matian Medical Corp. to furnish my attorney with a full report of his/her examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which I was recently involved. I hereby authorize and direct my attorney to pay Matian Medical Corp. such sum as may be due and owing it for medical services rendered me, by reason-of this accident and by reason of any other bills that are due his/her office and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately protect said doctor. And I hereby further give a lien on my case to Matian Medical Corp. against any all proceeds of any settlement, judgment or verdict which may be paid to my attorney or myself as the result of the injuries for which I have been treated or injuries in connection therewith. I agree never to rescind this document and that a rescission will not be honored by my attorney. I hereby instruct that in the event another attorney is substituted in this matter, the new attorney honor this lien as inherent to the settlement and enforceable upon the case as if it were executed by him/her. I fully understand that I am directly and fully responsible to Matian Medical Corp. for all medical and/or surgical benefits, including major medical, submitted by him/her for services rendered me and that this agreement is made solely for said doctor's additional protection. I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee. If this account is assigned for collection costs and/or interest, and/or attorneys fees, and/or court costs will be added to the total account. 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 may declare the entire balance due and payable.

PRESCRIPTION MEDICATION AGREEMENT:The purpose of this agreement is to prevent misunderstandings about certain medications I will be taking, including those that are controlled or potentially habit forming. This is to help me and my provider to comply with laws and recommendations regarding controlled pharmaceuticals. I understand that this Agreement is essential to the trust and confidence necessary in a doctor/patient relationship and that my provider undertakes to treat me based on this Agreement. I understand that if I break this Agreement, my provider will stop prescribing these pain control medicines and terminate my care. In this case, my doctor may taper off the medicine over a period of several days, as necessary, to avoid withdrawal symptoms and a drug-dependence treatment program may be recommended. I would also be amenable to seek psychiatric treatment, psychotherapy, and/or psychological treatment if my provider deems necessary. I will communicate fully with my provider about the character and intensity of my pain, the effect of the pain on my daily life, and how well the medicine is helping to relieve the pain. I understand that this office?s policy will include active participation in the Bureau of Narcotic Enforcement?s PDMP (Prescription Drug Monitoring Program) and CURES (Controlled Substance Utilization Review and Evaluation System) systems, which may include live database searches on my current and past medication use from any and all providers. I will not use any illegal controlled substances, nor will I misuse or self-prescribe/medicate with legal controlled substances. Use of alcohol will be limited to time when I am not driving, operating machinery and will be infrequent. I will not share, sell, or distribute my medication(s) with/to anyone. I will not attempt to obtain any controlled medications, including opioid pain medications, controlled stimulants, or anti-anxiety medications from any other provider. I will safeguard my medication from loss or theft. I agree that lost or stolen medications will not be replaced. I agree that my provider may or may not chose to refill my medications without an office exam as appropriate within legal limits and their medical judgment. I agree that refills of my prescriptions for pain medications will be made only at the time of an office visit or during regular office hours. I agree that no refills will be available during evenings or on weekends. I agree to use a pre-designated pharmacy* for filling my prescriptions for all of my pain medicine. I authorize my provider and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including this state's Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medication. I authorize my provider to provide a copy of this Agreement to my pharmacy, primary care physician and local emergency room. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations. I agree that I will submit to random and/or requested same-day testing of urine, blood, saliva, breath, hair, and/or other specimens, to determine my compliance with my program of pain control medications and/or the presence of any and all substances, including prescription medications, non-prescription medications, illicit drugs, illegal substances, and/or alcohol and the subsequent release of the results to government agencies and my employer, prospective employer, or other designated parties. I agree that I will use my medicine at a rate no greater that the prescribed rate and that use of my medicine at a greater rate will result in my being without medication for a period of time. I agree to bring unused pain medicine to every office visit. I agree to follow these guidelines that have been fully explained to me.

ASSIGNMENT OF BENEFITS / FINANCIAL AGREEMENT:I hereby authorize and assign to Matian Medical Corp. any and all benefit payments for services rendered under the terms of my insurance policies, and hereby individually obligate the payer to pay the account to Matian Medical Corp. in accordance with the standard and customary charges incurred during my period of treatment. I understand that I am responsible to pay for all charges for services rendered but not covered by my insurer. If I am liable for payment, a list of charges will be made available to me within sixty (60) days from the date Matian Medical Corp. becomes aware of my insurance ineligibility. I understand this may take up to 12 months as Matian Medical Corp. attempts to collect from my insurer. Should the account be referred for collection, I understand that I shall pay any collection expenses incurred by Matian Medical Corp., without limitation, court costs and attorney's fees. Patient co-payments and deductibles are due at the beginning of each visit. If my insurance is not confirmed before your first visit, a $300 fee will be charged at the time of my appointment. I may be offered a courtesy economic hardship discount if I do not have an insurance carrier and wish to pay in full at the time services are rendered. Such arrangements must be made at the time services are rendered or in advance and may not be may retroactively. Payments can be made with cash or accepted credit cards. If checks are accepted, there is a $50.00 fee on all returned checks. Outstanding and unpaid balances over 30 days will incur a 10% service charge per month unless previous written financial arrangements are satisfied. Chart duplicates require written request from the patient and a $35 fee. It is my responsibility to make sure that I am eligible for insurance coverage at Matian Medical Corp. I must inform the staff at this office of any changes in my insurance coverage. As a courtesy to me, they will bill my insurance company. I am responsible for the total payment of treatment until my insurance company has paid their portion of the balance and my account is cleared. Any outstanding insurance claims over 60 days become my responsibility, and must be paid in full at that time to avoid a 20% recurring monthly service fee. I understand that I am responsible for payment if any treatment is denied by my insurance company, I am not eligible for insurance, I prevent or delay payment by not complying with requests for insurance forms or signatures, I receive payment from my insurance company and do not send it to your office, or I do not complete my treatment and it results in non-payment by the insurance company. I am also responsible for payment if lab costs are incurred due to missing appointments. I hereby authorize payment directly to the above named physician of the group insurance benefit otherwise payable to me but not to exceed charges that will be incurred in my acceptance of treatment. I understand that I am financially responsible for any changes not covered by this authorization. Upon acceptance of a proposed treatment plan I authorize release of any information relating to this claim. I grant permission to be called at home or work to discuss matters related to this form. I have read the above conditions of this treatment and agree to their contents.

PHYSICIAN-PATIENT ARBITRATION AGREEMENT:Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 2: All claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or services provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term ?patient? herein shall mean both the mother and the mother?s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician?s partners, associates, association, corporation or partnership and the employees, agents and estates of any of them, must be arbitrated, including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filingof any action in any court by the physician to collect the assertion of any claim, against the physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. Each party to the arbitration shall pay such party?s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party?s own benefit. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in the arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provision of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statue of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitration shall be governed by the California Code of Civil Procedure provisions relating to arbitration. Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature and if not revoked will govern all medical services to the physician within 30 days of signature and if not revoked will govern all medical services received by the patient. Article 6: Retroactive Effect: This agreement is intended to cover services rendered before the date it is signed (including, but not limited to, emergency treatment). This agreement is effective as of the date of first medical services. If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I may request a copy of this arbitration agreement. By signing this contract I am agreeing to have any issue of medical malpractice decided by neutral arbitration and am giving up any right to a jury or court trial. See article 1 of this Contract.

Matian Medical Corp.TERMS OF USE.Matian Medical Corp. ("MMC") online services are supported by technology owned and operated by Doxy.me. THE TERMS BELOW GOVERN YOUR USE OF MATIAN MEDICAL CORP. TO AGREE TO THESE TERMS, CLICK "AGREE." IF YOU DO NOT AGREE TO THESE TERMS, DO NOT CLICK "AGREE," AND DO NOT USE THE SERVICES.DO NOT USE THIS SITE FOR EMERGENCY MEDICAL NEEDS. IF YOU EXPERIENCE A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.NOTICE OF PRIVACY PRACTICES. You may review the Notice of Privacy Practices of Matian Medical Corp., DBA Prime Care Physicians, ("MMC"), a physician group who may provide you with healthcare services via the Service. Note that by accepting these Terms of Use you are also acknowledging receipt of MMC's Notice of Privacy Practices.PRIVACY POLICY. NOTICE OF PRIVACY PRACTICES ? MATIAN MEDICAL CORP.For more information, contact:Matian Medical Corp. (the "Provider")Chief Privacy Officer.P.O. Box 55107Sherman Oaks, CA 91413. 818-995-7784. AUTHORIZATION FOR EVALUATION AND TREATMENT:I hereby authorize Matian Medical Corp., its affiliates, physicians, employees, and designated agents, to perform a physical examination and/or any medical treatment deemed necessary by the physician(s). These may include, without limitation, any required examination, medical, diagnostic or laboratory tests and medical procedures ordered by the physician(s) to be performed by the designated Matian Medical Corp. staff. I understand that certain special medical exams such as annual, executive, fitness for duty, school/sports physical exams, and other similar services are not intended for purposes of medical diagnosis and/or treatment, or to replace the medical care of my personal physician.CONSENT FOR NON-REGULATED SUBSTANCE ABUSE TESTING:When applicable, I voluntarily authorize Matian Medical Corp. to obtain a specimen of my urine, blood, saliva, breath, hair and/or other specimen, to determine the presence of drugs and/or alcohol, and subsequent release of the results to my employer/prospective employer, or another designated party.APPOINTMENTS:It is important that you arrive on time for your appointment. The office may need to reschedule me if I arrive more than 10 minutes past my appointment time. For legal reasons all patients under the age of 18 must be accompanied by an adult at all appointments, unless proper consent arrangements have been made with the doctor. All patients are required to go through our cycle of service. This starts on the first visit with a new patient well exam. A follow-up appointment will be made for any specific problems. If I need to reschedule or cancel my appointment I will give at least 24-hour advance notice. Matian Medical Corp. reserves the right to assess a $50.00 charge for missed appointments.PERSONAL INJURY, LITIGATED WORKMANS' COMPENSATION, AND OTHER LIEN CASES:I do hereby authorize Matian Medical Corp. to furnish my attorney with a full report of his/her examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which I was recently involved. I hereby authorize and direct my attorney to pay Matian Medical Corp. such sum as may be due and owing it for medical services rendered me, by reason-of this accident and by reason of any other bills that are due his/her office and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately protect said doctor. And I hereby further give a lien on my case to Matian Medical Corp. against any all proceeds of any settlement, judgment or verdict which may be paid to my attorney or myself as the result of the injuries for which I have been treated or injuries in connection therewith. I agree never to rescind this document and that a rescission will not be honored by my attorney. I hereby instruct that in the event another attorney is substituted in this matter, the new attorney honor this lien as inherent to the settlement and enforceable upon the case as if it were executed by him/her. I fully understand that I am directly and fully responsible to Matian Medical Corp. for all medical and/or surgical benefits, including major medical, submitted by him/her for services rendered me and that this agreement is made solely for said doctor's additional protection. I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee. If this account is assigned for collection costs and/or interest, and/or attorneys fees, and/or court costs will be added to the total account. 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 may declare the entire balance due and payable.HIPAA Notice of Privacy Practices.THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 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 your physician, 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 physician's practice, 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 a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.We may use or disclose your protected health information in the following situations without your authorization. These situations include: 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: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers' Compensation: Inmates: 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 Use 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 the physician's practice has taken on 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.Your physician is not required to agree to a restriction that you may request. If physician 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 i.e. electronically. You may have the right to have your physician 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. This notice was published, and becomes effective on/or before April 14, 2003. 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 objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.Signature below is only acknowledgement that you have received this Notice of our Privacy Practices.PRESCRIPTION MEDICATION AGREEMENT.The purpose of this agreement is to prevent misunderstandings about certain medications I will be taking, including those that are controlled or potentially habit forming. This is to help me and my provider to comply with laws and recommendations regarding controlled pharmaceuticals. I understand that this Agreement is essential to the trust and confidence necessary in a doctor/patient relationship and that my provider undertakes to treat me based on this Agreement. I understand that if I break this Agreement, my provider will stop prescribing these pain control medicines and terminate my care. In this case, my doctor may taper off the medicine over a period of several days, as necessary, to avoid withdrawal symptoms and a drug-dependence treatment program may be recommended. I would also be amenable to seek psychiatric treatment, psychotherapy, and/or psychological treatment if my provider deems necessary. I will communicate fully with my provider about the character and intensity of my pain, the effect of the pain on my daily life, and how well the medicine is helping to relieve the pain.I understand that this office?s policy will include active participation in the Bureau of Narcotic Enforcement?s PDMP (Prescription Drug Monitoring Program) and CURES (Controlled Substance Utilization Review and Evaluation System) systems, which may include live database searches on my current and past medication use from any and all providers.I will not use any illegal controlled substances, nor will I misuse or self-prescribe/medicate with legal controlled substances. Use of alcohol will be limited to time when I am not driving, operating machinery and will be infrequent.I will not share, sell, or distribute my medication(s) with/to anyone.I will not attempt to obtain any controlled medications, including opioid pain medications, controlled stimulants, or anti-anxiety medications from any other provider.I will safeguard my medication from loss or theft.I agree that lost or stolen medications will not be replaced.I agree that my provider may or may not chose to refill my medications without an office exam as appropriate within legal limits and their medical judgment.I agree that refills of my prescriptions for pain medications will be made only at the time of an office visit or during regular office hours.I agree that no refills will be available during evenings or on weekends.I agree to use a pre-designated pharmacy* for filling my prescriptions for all of my pain medicine.I authorize my provider and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including this state's Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medication.I authorize my provider to provide a copy of this Agreement to my pharmacy, primary care physician and local emergency room.I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations.I agree that I will submit to random and/or requested same-day testing of urine, blood, saliva, breath, hair, and/or other specimens, to determine my compliance with my program of pain control medications and/or the presence of any and all substances, including prescription medications, non-prescription medications, illicit drugs, illegal substances, and/or alcohol and the subsequent release of the results to government agencies and my employer, prospective employer, or other designated parties.I agree that I will use my medicine at a rate no greater that the prescribed rate and that use of my medicine at a greater rate will result in my being without medication for a period of time.I agree to bring unused pain medicine to every office visit.I agree to follow these guidelines that have been fully explained to me.PHYSICIAN-PATIENT ARBITRATION AGREEMENTArticle 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.Article 2: All claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or services provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term ?patient? herein shall mean both the mother and the mother?s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician?s partners, associates, association, corporation or partnership and the employees, agents and estates of any of them, must be arbitrated, including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect the assertion of any claim, against the physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. Each party to the arbitration shall pay such party?s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party?s own benefit. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in the arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provision of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure.Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statue of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitration shall be governed by the California Code of Civil Procedure provisions relating to arbitration.Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature and if not revoked will govern all medical services to the physician within 30 days of signature and if not revoked will govern all medical services received by the patient.Article 6: Retroactive Effect: This agreement is intended to cover services rendered before the date it is signed (including, but not limited to, emergency treatment). This agreement is effective as of the date of first medical services.If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I may request a copy of this arbitration agreement. By signing this contract I am agreeing to have any issue of medical malpractice decided by neutral arbitration and am giving up any right to a jury or court trial. See article 1 of this Contract.ASSIGNMENT OF BENEFITS / FINANCIAL AGREEMENTI hereby authorize and assign to Matian Medical Corp. any and all benefit payments for services rendered under the terms of my insurance policies, and hereby individually obligate the payer to pay the account to Matian Medical Corp. in accordance with the standard and customary charges incurred during my period of treatment. I understand that I am responsible to pay for all charges for services rendered but not covered by my insurer. If I am liable for payment, a list of charges will be made available to me within sixty (60) days from the date Matian Medical Corp. becomes aware of my insurance ineligibility. I understand this may take up to 12 months as Matian Medical Corp. attempts to collect from my insurer. Should the account be referred for collection, I understand that I shall pay any collection expenses incurred by Matian Medical Corp., without limitation, court costs and attorney's fees. Patient co-payments and deductibles are due at the beginning of each visit. If my insurance is not confirmed before your first visit, a $300 fee will be charged at the time of my appointment. I may be offered a courtesy economic hardship discount if I do not have an insurance carrier and wish to pay in full at the time services are rendered. Such arrangements must be made at the time services are rendered or in advance and may not be may retroactively. Payments can be made with cash or accepted credit cards. If checks are accepted, there is a $50.00 fee on all returned checks. Outstanding and unpaid balances over 30 days will incur a 10% service charge per month unless previous written financial arrangements are satisfied. Chart duplicates require written request from the patient and a $35 fee. It is my responsibility to make sure that I am eligible for insurance coverage at Matian Medical Corp. I must inform the staff at this office of any changes in my insurance coverage. As a courtesy to me, they will bill my insurance company. I am responsible for the total payment of treatment until my insurance company has paid their portion of the balance and my account is cleared. Any outstanding insurance claims over 60 days become my responsibility, and must be paid in full at that time to avoid a 20% recurring monthly service fee. I understand that I am responsible for payment if any treatment is denied by my insurance company, I am not eligible for insurance, I prevent or delay payment by not complying with requests for insurance forms or signatures, I receive payment from my insurance company and do not send it to your office, or I do not complete my treatment and it results in non-payment by the insurance company. I am also responsible for payment if lab costs are incurred due to missing appointments. I hereby authorize payment directly to the above named physician of the group insurance benefit otherwise payable to me but not to exceed charges that will be incurred in my acceptance of treatment. I understand that I am financially responsible for any changes not covered by this authorization. Upon acceptance of a proposed treatment plan I authorize release of any information relating to this claim. I grant permission to be called at home or work to discuss matters related to this form. I have read the above conditions of this treatment and agree to their content.Your Information. Your Rights. Our Responsibilities.This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.Your Rights.You have the right to:? Get a copy of your electronic medical record? Correct your electronic medical record? Request confidential communication? Ask us to limit the information we share? Get a list of those with whom we've shared your information? Get a copy of this privacy notice? Choose someone to act for you? File a complaint if you believe your privacy rights have been violated.YOUR USE OF MATIAN MEDICAL CORP:You acknowledge that you are consenting to receiving care via Matian Medical Corp.. The scope of care will be at the sole discretion of the health services provider who is treating you, with no guarantee of diagnosis, treatment, or prescription. The health services provider will determine whether or not the condition being diagnosed and/or treated is appropriate for a telehealth encounter via Matian Medical Corp.. You understand and agree that your interaction with health services providers using Matian Medical Corp. is not intended to take the place of appointments with your regular primary care provider. Do not disregard medical advice from your regular doctor or other health professional because of information provided by a health services provider via Matian Medical Corp.INFORMATION ABOUT HEALTH SERVICES PROVIDERSHealth services providers are licensed by applicable state medical boards. For more information about a health services provider's licensure, you can contact the medical board in your state.INFORMED CONSENT FOR SERVICES PERFORMED BY HEALTH SERVICES PROVIDER.We are providing this information on behalf of the health services provider:The delivery of health care through services using communication tools such as Matian Medical Corp. is commonly called "Telemedicine." Telemedicine involves the use of electronic communications to enable health care providers at sites remote from patients to provide consultative services. The information may be used for diagnosis, therapy, follow-up and/or education, and may include live two-way audio and video and other materials (e.g. medical records, data from medical devices).The communications systems used will incorporate network and software security protocols to protect the confidentiality of patient information and will include reasonable measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.A visit summary may be provided to you at the end of each visit which may be kept for your records and may be shared with your local primary care or other provider, as appropriate.INFORMED CONSENT.By clicking the "AGREE" button you acknowledge that you are consenting to receiving care via the Service. The scope of care will be at the sole discretion of the healthcare provider who is treating you, with no guarantee of diagnosis, treatment, or prescription. The healthcare provider will determine whether or not the condition being diagnosed and/or treated is appropriate for a telehealth encounter via the Service. The Service respects and upholds patient confidentiality with respect to protected health information as outlined by the Health Insurance Portability and Accountability Act ("HIPAA"), and, subject to HIPAA regulations, will obtain express patient consent prior to sharing any patient-identifiable information to a third party for purposes other than treatment, payment or health care operations. In addition, by clicking the "AGREE" button you are authorizing MMC to provide you with marketing materials promoting the Service. You may opt out of receiving such marketing materials by contacting us at info@primecarela.com.Anticipated Benefits of Telemedicine:?Improved access to medical care by enabling a patient to remain at his or her home or office while consulting a clinician.?More efficient medical evaluation and management.Possible Risks of Telemedicine:As with any medical procedure, there are potential risks associated with the use of telemedicine. MMC believes that the likelihood of these risks materializing is very low. These risks may include, without limitation, the following:?Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment.?Security protocols could fail, causing a breach of privacy of personal medical information.?Lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other negative outcomes.By accepting these Terms of Use, you acknowledge that you understand and agree with the following:1.I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine; I have received the MMC Notice of Privacy Practices which explains these issues in greater detail.2.I understand that telemedicine may involve electronic communication of my personal medical information to medical practitioners who may be located in other areas, including out of state.3.I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.4.I understand that my healthcare information may be shared with other individuals for treatment, payment and healthcare operations purposes. Psychotherapy notes are maintained by clinicians but are not shared with others, while billing codes and encounter summaries are shared with others and with me. If I obtain psychotherapy from MMC, I understand that my therapist has the right to limit the information provided to me if in my therapist's professional judgment sharing the information with me would be harmful to me.5.I further understand that my healthcare information may be shared in the following circumstances:a)When a valid court order is issued for medical records.b)Reporting suspected abuse, neglect, or domestic violence.c)Preventing or reducing a serious threat to anyone's health or safety.Patient Consent to the Use of Telemedicine.I have read and understand the information provided above, and understand the risks and benefits of telemedicine, and by accepting these Terms of Use I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.PAYMENT AUTHORIZATION:By accepting these terms of use, you are authorizing American Well to charge your credit card for the full amount due from you with respect to your consultation. Please note that American Well may not be given full or complete information from your health plan regarding the applicable co-pay due from you for your consultation. As such, you may be billed multiple times with respect to a consultation ? once prior to beginning the visit and a second time once your health plan has advised us as to what additional co-pays, if any, you owe.I understand that this authorization to bill my credit card or debit card (including any other American Well accepted payment mechanism) will remain in effect until I cancel it in writing, and I agree to notify American Well in writing of any changes in my account information. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF), I understand that American Well may at its discretion attempt to process the charge again at any time within 30 days. 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 card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the co-payment required by my health plan.CHARGES FOR SERVICES:You understand and agree that you are responsible for all charges relating to your use of Matian Medical Corp. that are not covered by your insurance.You will be informed of the fee to be charged when you select a health services provider. Fees may vary from provider to provider. You will be responsible for all charges related to your online visit that are not covered by your insurance. You authorize MMC to charge your credit card for any portion of the visit fee that is not covered by your insurance. You will be asked to supply credit card information, which will be verified prior to your online visit. You will not be able to use Matian Medical Corp. to communicate with a health services provider if the credit card information you provide is inaccurate or if your credit card is declined.By initiating an online visit you authorize us to charge your credit card for any charges that are your responsibility.In order to facilitate payment for your online visit, we will share your credit card information and related personal information with the designated credit card payment processor. This information is shared solely for the purpose of collecting the fee.In the event there is a connection disruption within the first ninety (90) seconds of the visit, no charge will be incurred. Thereafter, if there is an interruption, in the video, but you and your selected provider can re-connect or remain connected by video or telephone, the stated charge will still be made.PASSWORDS AND ACCOUNT. Your username and password ("Log-In ID") will allow you to access Matian Medical Corp. You are solely responsible for controlling your Log-In ID, and are prohibited from making it available to anyone else. You are responsible for all activities that occur under your Log-In ID. You agree to notify Matian Medical Corp. Customer Support at 818-995-7784 immediately of any unauthorized use of your Log-In ID or of any need to reset or lock down the Log-In ID associated with your account.YOUR COMMUNICATIONS.You are responsible for your own communications using Matian Medical Corp.. You may not:communicate material that is obscene, defamatory, threatening, harassing, abusive, hateful, or embarrassing to any person or entity;communicate a sexually-explicit image;communicate chain letters or pyramid schemes;impersonate another person;violate the Children's On Line Privacy Protection Act;communicate material that is copyrighted, without the permission of the copyright owner;communicate material that reveals trade secrets, unless you have permission of the owner,communicate material that infringes on any other intellectual property rights of others or on the privacy or.publicity rights of others.TERMINATION MMC may terminate your use this site at any time. MMC reserves the right to block, delete or stop the uploading of materials and communications that it, in its sole discretion, finds unacceptable for any reason. If your use of this site is terminated you shall make no further use of Matian Medical Corp. or any information obtained from it. If you find that you have been terminated, you may contact Matian Medical Corp. Customer Support at 818-995-7784 for further information.APPROPRIATENESS OF CONTENT. Matian Medical Corp. is not intended for independent use by children under the age of 18. Children under 18 must be enrolled on the site under their parent or guardian's account as a dependent. Parents or guardians are solely responsible for being present with their minor children when using the Matian Medical Corp. tool.NO LIABILITY FOR COMPUTERS AND NETWORKS USED TO ACCESS YOUR ACCOUNT.We are only responsible for the security of the computer systems we own and operate. MMC shall have no liability for information about you stored or recorded by any computer or mobile device or any network, whether public or private, that you may use to access Matian Medical Corp..ACCEPTABLE USE MMC makes the Matian Medical Corp. website and application available for the sole purpose of facilitating communications between health services providers and consumers who chose to use the online service. You agree not to access or use Matian Medical Corp. for an unlawful or illegitimate purpose. You shall not attempt to disrupt the operation of the services or the Matian Medical Corp. system. You shall not attempt to gain unauthorized access to any user accounts or computer systems or networks.OPERATION AND RECORD RETENTION MMC reserves complete and sole discretion with respect to the operation of Matian Medical Corp.. MMC may withdraw, suspend or discontinue any functionality or feature of the services. MMC reserves the right to maintain, delete or destroy all communications and materials posted or uploaded to the Matian Medical Corp. system pursuant to its internal record retention and/or destruction policies.INTELLECTUAL PROPERT:All of the content available on or through Matian Medical Corp. is the property of MMC or American Well or their licensors, and is protected by copyright, trademark, patent, trade secret and other intellectual property laws. We give you permission to display, download, store, and print the content only for your personal, non-commercial use. You agree not to reproduce, retransmit, distribute, disseminate, sell, publish, broadcast, or circulate the content received using Matian Medical Corp. to anyone. All software and accompanying documentation made available for download from Matian Medical Corp. is the copyrighted work of MMC.All Matian Medical Corp. and Prime Care Physicians trade and service names are trademarks of Matian Medical Corp. All other brands and names, including "Prime Care Physicians," are the property of their respective owners. Nothing contained on Matian Medical Corp. or it?s affiliated web sites should be construed as granting any license or right to use any trademark displayed on this site without the express written permission of MMC, Prime Care Physicians, or any other party that may own the trademark.Subject to these terms, MMC hereby grants you a limited, revocable, non-transferable and non-exclusive license to use the software, network facilities, content and documentation on and in Matian Medical Corp. to the extent, and only to the extent, necessary to access and use Matian Medical Corp. for your personal use.DIGITAL MILLENIUM COPYRIGHT ACT :MMC respects the intellectual property of others and expects its users to do the same. If you believe that your copyrighted work has been copied in a way that constitutes copyright infringement and is accessible on this site or through this service, you must provide the following information when providing notice of the claimed infringement to MMC:A physical or electronic signature of a person authorized to act on behalf of the copyright owner and identification of the copyrighted work that is infringed;Information reasonably sufficient to permit MMC to contact you, such as an address, telephone number and/or electronic mail address;A statement that you have a good faith belief that the use of the material in the manner complained of is not authorized by the copyright owner, its agent or law;A statement that the information in the notification is accurate and under penalty of perjury, that the complaining party is authorized to act on behalf of the owner of an exclusive right that is allegedly infringed.The above information must be submitted as a written notification to MMC through MMC Customer Service at info@primecarela.com or P.O. Box 55107, Sherman Oaks, CA 91413, ATTENTION: LEGAL DEPARTMENT/DMCA COMPLAINT. This information should not be construed as legal advice. For further details on the information required for valid DMCA notifications, see 17 U.S.C. 512(c)(3).LIABILITY OF MMC AND ITS LICENSORS AND SUPPLIER.No Liability. MMC AND ITS LICENSORS AND SUPPLIERS (INCLUDING, FOR THE PURPOSES OF THIS ENTIRE SECTION, ALL PROVIDERS OF CONTENT FOR MATIAN MEDICAL CORP.) SHALL NOT BE LIABLE TO YOU, UNDER ANY CIRCUMSTANCES OR UNDER ANY THEORY OF LIABILITY OR INDEMNITY, FOR ANY DAMAGES OR PENALTIES WHATSOEVER (INCLUDING, WITHOUT LIMITATION, INCIDENTAL INDIRECT, EXEMPLARY, PUNITIVE AND CONSEQUENTIAL DAMAGES, LOST PROFITS, OR DAMAGES RESULTING FROM LOST DATA OR BUSINESS INTERRUPTION) IN CONNECTION WITH THE USE OR INABILITY TO USE MATIAN MEDICAL CORP. OR THE CONTENT, EVEN IF ANY OF THEM HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. MMC SHALL BE LIABLE TO YOU ONLY TO THE EXTENT OF ACTUAL DAMAGES INCURRED BY YOU. THE REMEDIES STATED FOR YOU IN THESE TERMS AND CONDITIONS ARE EXCLUSIVE AND ARE LIMITED TO THOSE EXPRESSLY PROVIDED FOR IN THESE TERMS AND CONDITIONS.MMC and its licensors and suppliers are not responsible for any claims you may have against any medical professionals, suppliers of products or other persons, institutions or entities identified in whole or in part through Matian Medical Corp..NO WARRANTIES. MATIAN MEDICAL CORP., AND ITS CONTENT AND INFORMATION ARE PROVIDED "AS IS." MMC, ITS LICENSORS AND SUPPLIERS DISCLAIM ALL WARRANTIES OF ANY KIND, WHETHER EXPRESS OR IMPLIED, STATUTORY OR OTHERWISE, INCLUDING BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, NONINFRINGEMENT OF THIRD PARTIES RIGHTS OR FITNESS FOR A PARTICULAR PURPOSE.MMC, ITS LICENSORS AND SUPPLIERS MAKE NO REPRESENTATIONS OR WARRANTIES THAT THE INFORMATION PROVIDED ON MATIAN MEDICAL CORP. IS COMPLETE, EXHAUSTIVE, RELIABLE, CURRENT OR ACCURATE. NO CLAIMS OR ENDORSEMENTS ARE MADE FOR ANY DRUG, HERB, SUPPLEMENT, COMPOUND, THERAPY, OR TREATMENT.INDEMNIFICATION:Without limiting the generality or effect of other provisions of these terms, as a condition of use, you agree to indemnify and hold harmless MMC and its licensors and suppliers and their parents, subsidiaries, affiliates, suppliers and their officers, directors, affiliates, subcontractors, agents and employees (collectively, "Indemnified Parties" and each, individually, an "Indemnified Party") against all costs, expenses, liabilities and damages (including attorney's fees) incurred by any Indemnified Party in connection with any third party claims arising out of: (i) your use of Matian Medical Corp. and/or your receipt of services; (ii) your failure to comply with any applicable laws and regulations; and (iii) your breach of any of your obligations set forth here. You shall not settle any such claim without the written consent of the applicable Indemnified Party.CHANGES TO THIS NOTICE :MMC may revise, modify or amend the information contained on this page at any time. Any such revision, modification or amendment shall be effective immediately upon either posting it to this web site or otherwise notifying you.MISCELLANEOUS:MMC is based in Los Angeles, California in the United States of America and makes no claims that the content and information included on Matian Medical Corp. is appropriate or may be downloaded outside of the United States. Access to the content and information may not be legal by certain persons or in certain countries. If you access Matian Medical Corp. from outside the United States, you do so at your own risk and are solely responsible for compliance with the laws of your jurisdiction and any other applicable laws.These terms of use shall be governed and construed in accordance with the laws of the State of Indiana without regard to the choice of law provisions of any jurisdiction. MMC may without notice to you assign its rights and duties hereunder to any party at any time. Failure to enforce or insist on strict performance of any provision of these terms shall not be construed as a waiver of any provision or right. You agree that any legal action or proceeding between MMC and you in any way related to these terms of use shall be brought exclusively in a court of a competent jurisdiction sitting in Indianapolis, Indiana. Any cause of action or claim you may have against or involving MMC must be commenced within one year after the claim or cause of action arises. Neither the course of conduct between the parties nor trade practice shall modify these terms. The invalidity or unenforceability of any provision shall not in any way affect the validity or enforceability of the rest of these terms.You understand and agree that American Well is a third party beneficiary to this agreement and has the right to enforce any of its terms.NOTICES:To the extent that the law and/or any applicable regulation allows for the provision of notice electronically, your use of Matian Medical Corp. constitutes your agreement to receive all such notices electronically, including but not limited to notices required by state or federal privacy laws, and all financial information pertinent to, or required in connection with the operation of Matian Medical Corp..QUESTIONS:If you have questions or comments or if you believe that your confidentiality has been breached or that any of your communications have been intercepted, or you wish to notify us regarding a suspected violation of these terms, please contact Matian Medical Corp. Customer Support by email at info@primecarela.com or call toll free at 818-995-7784immediately.© 2018 MMC. All rights reserved.Revised May 5, 2018.AMERICAN WELL CORPORATION PRIVACY POLICY:We are committed to ensuring that your personal information shared over our Site and/or Services is protected and kept confidential. By accepting Company's Terms of Use or providing information to us via our Site, you consent to the use and disclosure of personally identifiable information as outlined in this Privacy Policy. Please note that the use and disclosure of such information is also subject to the practices of the health care providers with whom you may interact through the Services, as described in the Notice of Privacy Practices which is provided to you by such providers.INFORMATION COLLECTION:Personal information or protected health information is information that includes, but is not limited to, identifying data such as name, social security number, address, contact information, as well as information about personal health issues submitted through the Services.This is the information we aim to protect.We will only collect information that you voluntarily submit. We know that privacy is of the utmost importance.We vigorously believe in keeping confidential any and all personally identifiable information that identifies an individual whether or not it relates to an individual's past, present, or future physical or mental health condition.As a Business Associate of health care providers that are Covered Entities under the federal health care privacy and security rules (HIPAA and HITECH), we maintain protected health information (PHI) in compliance with these rules and our contractual obligations with health care providers. Currently our main focus is providing a platform to allow individuals to receive telehealth Services from various healthcare providers. We collect information solely for the purposes of providing the Services, marketing and promoting our Services to you and for market research data.We assume you are giving consent to this information collection and use, but we also give you the opportunity to "opt out" of receiving direct marketing or market research information by emailing us at info@primecarela.com.We maintain web logs to record data about all visitors who use this site and interact with the Services and we will store this information. These logs may contain IP address information, types of operating system you use, the date and time you visited the site, and information about the type of device you use to connect to the Services.All Web logs are stored securely and are accessible to a very limited number of employees and contractors, who have to adhere to strict guidelines regarding user data security and privacy.NON-PERSONAL IDENTIFICATION/COOKIES TECHNOLOGY:What is a cookie? A cookie is a small data file that certain web sites write to your hard drive when you visit them. A cookie file, for instance, may collect user ID information such as items in a shopping cart while navigating a site, but the only personal information a cookie can contain is information you provide. Your user ID or profile information is not stored in cookies.How do we use cookie technology? We use it in the aggregate as opposed to using any personally identifiable information, to understand how our users collectively use our Site. This helps us continually improve our Site.Most web browsers are set to accept cookies, but if you prefer not to receive cookies you can set your browser to warn you or refuse cookies all together by turning them off in your browser. We may also use non-personal information to analyze data into useful information. This process of data mining is done in the aggregate, is non-personal, and allows Company to find correlations and patterns in the data.SECURITY OF INFORMATION COLLECTED:We use account information in a password-protected environment as a security measure to protect your data.We use administrative, physical and technical safeguards to protect data. We maintain a high level of data protection via safeguards such as data backup, audit controls, access controls, and some data encryption. Our Site and the Services use industry standard SSL encryption to enhance security of electronic data transmissions. In addition, we urge you to take precautionary measures in maintaining the integrity of your data. Please be responsible in making sure no one can see or has access to your personal account and log-in/password information. If you use a public computer, e.g., at a library or a university, always remember to log out of the Site or Services.If you use our Site or Services through your employer's computer network or through an internet café, library or other potentially non-secure internet connection, such use is at your own risk. It is your responsibility to check beforehand on your employer's or such other site's privacy and security policy with respect to Internet use.We are not responsible for your handling, sharing, re-sharing and/or distribution of your personal health information. Moreover, if you forward personal health information electronically to another person on or off the Site or Service, we are not responsible for any harm or other consequences from third party use or re-sharing of your information.SELF REVIEW OF DATA AND ABILITY TO DELETE YOUR ACCOUNT INFORMATION:You may request to delete any personal information and to de-authorize the collection of personal information in the future by sending us an email at info@primecarela.com.THIRD PARTY SITES/TRUSTED RELATIONSHIPS:As noted above, the Company is a Business Associate of health care providers under HIPAA and we share information with health care providers who provide services to individuals, and they share information with us, for purposes related to treatment, payment and health care operations, and otherwise as agreed or authorized by you.Our Site contains links to other sites. We do not share your personally identifiable information with those sites (unless you specifically authorize such sharing) and are not responsible for their privacy procedures. We seek to work with trusted partners and organizations that will adhere to similar privacy and ethical standards. However, we encourage you to learn their particular privacy policies.We disclose personally identifiable information about you as required or permitted by law, including complying with legal process (for example, we may disclose your information as necessary to comply with an authorized civil, criminal or regulatory investigation). We fully cooperate with law enforcement agencies in identifying those who use our services for illegal activities and may, in our sole discretion, disclose personal information or other information to satisfy any law, regulation, subpoena, or government request. We reserve the right to release personal information or other information about users who we believe are engaged in illegal activities or are otherwise in violation of our Terms of Use, even without a subpoena, warrant or court order, if we believe, in our sole discretion, that such disclosure is necessary or appropriate to operate our web site or to protect our rights or property, or that of our affiliates, or our officers, directors, employees, agents, third-party content providers, suppliers, sponsors, or licensors. We also reserve the right to report to law enforcement agencies any activities we reasonably believe in our sole discretion to be unlawful. If we are legally compelled to disclose information about you to a third party, we will attempt to notify you by sending an email to the email address in our records unless doing so would violate the law or unless you have not provided your email address to us.CHILDREN:We do not knowingly allow individuals under the age 18 to create accounts that allow access to our Site.CHANGES TO THIS PRIVACY POLICY:We may amend our Privacy Policy in the future. In the event changes are made, we will be sure to post changes at the Site and at other places we deem appropriate.QUESTIONS OR SUGGESTIONS.If you have any questions or suggestions on ways we can improve our privacy policy with respect to personal information, please email us at info@primecarela.com.

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