Leave the following information on your HOME / CELL answering machine/voicemail:

Leave the following information on your WORK answering machine / voicemail:

I give permission to share appointment information with the person/persons named below:

I give permission to share medical information including biopsy and lab results with the person/persons listed below:

ASSIGNMENT OF RIGHTS AND BENEFITS WITIDN THE MEANING OF 627.736, FLORIDA STATUTES: I, the below named patient/insured, in consideration for being treated by Surgery Consultants of Florida without payment in full at the time of treatment (or in advance of treatment), hereby fully and completely assign over to Surgery Consultants of Florida any and all MedPay benefits and Personal Injury Protection (PIP) rights and benefits (including but not limited to the right to sue and the right to compromise claims) to which I am entitled by virtue of Florida Statute 627.736 and/or any policy of insurance providing Personal Injury Protection benefits and/or MedPay benefits.

This assignment also includes and is not limited to the right to reimbursement of transportation costs, my right to bad faith claims and any
and all rights I may have to notice of, attendance of counsel to, and copies or transcripts or reports of, any EUO (Examination Under Oath),
any IME (Independent Medical Examination) scheduled or taken by any insurance carrier regarding treatment provided by Surgery
Consultants of Florida, peer review reports, copies of insurance policies, declaration pages and PIP logs. As additional consideration I also agree as follows:

• A. I agree and stipulate that venue for any litigation involving the payment of any benefits under any policy which may cover me shall be in Sarasota County, Florida.
• B. I agree and stipulate that should my attorney or representative request a reduction of any costs or fees payable by me personally that my attorney or representative must provide to Surgery Consultants of Florida the terms of the settlement or recovery obtained by me as well as an accurate and complete copy of the actual settlement statement and disbursement statement for my case.
• C. I grant to Surgery Consultants of Florida, full power and authority to endorse and sign checks or drafts for payment of bills submitted by Surgery Consultants of Florida, for services rendered to me by them.
• D. I authorize and direct my present or future attorneys and my Personal Injury Protection insurance carrier or carriers to release any and all medical and legal information in their possession about me to Surgery Consultants of Florida immediately upon demand.

If any portion of this document is deemed to be inconsistent with an assignment of rights and benefits within the meaning of 627.736, Florida
Statutes, or said policy of insurance said portion shall be rewritten in order to conform with Florida law to give full effect to the intended purpose of this agreement, said intended purpose being to create an assignment of rights and benefits from the below named patient I insured to Surgery Consultants of Florida

INFORMED CONSENT TO TREAT: I fully understand that Surgery Consultants of Florida is a multidisciplinary organization and that I may be seen by an M.D., D.O., D.C., P.A., N.P., L.M.T. or a combination of them. I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risks of injury or even death. I also understand that no guarantee or promise has been made as to the result that may be obtained.

LIVING WILL I ADVANCE DIRECTIVE: Surgery Consultants does not honor living wills I advance directives. In the event of a life threatening emergency, 911 will be called. If you would like more information, please contact our front desk and they will direct you to the proper person in our organization to speak with.

APPLICANT'S AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS: I hereby authorize in accordance to the Health Insurance Portability and Accountability Act of1996 (HIPAA) -privacy and security requirements that any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, or other organization, institution or person, that has any records or knowledge of me or my health, to release such information to Surgery Consultants of Florida I also give my permission for Surgery Consultants of Florida to RELEASE ANY of my records to a medical provider or facility, or to my attorney requesting such information FROM Surgery Consultants of Florida and to any insurance company responsible for payment. This release specifically includes but is not limited to authorization to release any and all medical records and information associated with (or in reference to) the following conditions: Positive exposure to HIV infection, ARC, AIDS, alcohol or drug dependency, mental and nervous disorders. A photographic copy of this authorization shall be valid as the original. This authorization shall be valid for five years from the date of signature. I give permission to my current attorney or any attorney in the future representing me to access my medical records electronically.

GUARANTEE OF PAYMENT: I agree to be fully responsible for all costs and services provided to me, including transportation charges. I understand that I am responsible for any costs incurred in the collection of my account (s) in case of default, including reasonable attorney's fees and costs. I also grant Surgery Consultants of Florida a lien against any recovery that I may have now or in the future against any tortfeasor or any responsible insurance carrier. I also agree that if!, my attorney or representative request a narrative report regarding my condition that the cost of such report shall be my responsibility because such a report is not compensable under PIP coverage. I promise to sign a letter of protection in favor of Surgery Consultants of Florida and hereby direct that any attorney representing me now or in the future to execute that certain letter of protection in favor of Surgery Consultants of Florida that has been previously executed by me.

STATEMENT OF TRUTHFULNESS: I state that any and all of the information provided to Surgery Consultants of Florida concerning my financial information, insurance information, accident and automobile information, and any information concerning coverage under any type of health care plan is true and correct. I further understand and acknowledge that if any of the information I provide Surgery Consultants of Florida is in any way incorrect or untrue, then I may be liable for damages and penalties for violating this agreement and Florida law, including but not limited to Florida Statute 817.50 which prohibits a person from fraudulently obtaining services from a medical facility.

The undersigned has read this entire document, agrees to its terms and conditions and authorizes it and the underlying
signature may be electronically copied, stored and reproduced and any such copied, stored or reproduced version be used as
an original.

Provider: Surgery Consultants of Florida

I, the undersigned patient, hereby instruct my attorney to acknowledge receipt of this Irrevocable Payment Agreement herein referred to as “Agreement”, in favor of Provider to insure that Provider is paid in full for any and all treatment and services provided by it to me, or on my behalf, as a result of the accident that took place on or about the date of loss described above, regardless of the outcome of a trial or what a jury may award me for the injuries that I have suffered. I understand that recovery is often uncertain, owing to the strategies, tactics and opinions offered at trial by defense lawyers who are working for insurance companies with significant resources to combat the reasonable claims brought by me, the injured patient. Provider is acting in reliance on the terms of this agreement for the provision of treatment and services.

Unfortunately, until the at-fault driver, or his/her insurance carrier, (the at-fault insurance company), on the at-fault driver’s behalf, accepts responsibility for the negligent conduct, I have no way to compensate said Provider for the care and treatment that it will provide me under this agreement. Despite the fact that the at-fault driver is insured under a policy of insurance that provides for bodily injury coverage, the at-fault insurance carrier has not fully accepted responsibility for the negligent conduct of their insured. Because of the delay on the part of the at-fault insurance carrier, I hereby request that my attorney protect and pay my outstanding charges, after attorney’s fees and costs, from any settlement or funds received by me, or in my beneficial interest, from any source (BI and/or UM insurance coverage), as compensation for any damages I may have sustained as a result of the events that occurred on or about the date of loss described above. I further authorize my attorney to enter into a different agreement acceptable to my attorney and Provider, but if no agreement is made, then I instruct that this agreement shall be the one in force and instruct my attorney to comply with its terms and conditions. I further instruct that my instructions to attorney herein are irrevocable and shall and are transferable to any future attorney of mine in the event that I change my legal representation in regard to the damages contemplated herein.

The terms of this assignment are as follows:

• This agreement shall not be sold, assigned or transferred except to any future attorney in the event I change legal representation.
• Upon request and periodically, Provider will forward updated bills and medical records to the patient or to the patient’s attorney and not to the Patient, unless requested otherwise in writing.
• Provider shall refrain from any and all collection efforts during litigation.
• If my attorney or representative requests a reduction of any costs or fees payable to Provider, I authorize my attorney or representative to provide said Provider with a copy of the partial closing statement or final closing statement and/or the terms of any negotiation or potential recovery to be obtained in my favor.
• Should Provider or Patient not agree to payment to Provider, and/or Provider and Patient’s attorney, (acting solely on behalf of Patient) cannot effect a compromise, then Patient’s attorney shall deposit funds, in an amount no less than the disputed charges, in the registry of the court for appropriate judicial determination of distribution by a motion for equitable distribution or independent interpleader action.
• It is agreed upon by Provider and Patient that should the foregoing become necessary, Patient’s attorney shall be entitled to recoup any costs incurred, exclusive of attorney’s fees.
• The terms contained herein are accepted as adequate consideration for this agreement by the signatories below.

Florida Statue 456.052 requires that a healthcare provider must advise the patient:

• a) Of their right to choose the medical provider or supplier of any referral services,
• b) Provide its patients with a written disclosure form informing of any investment interest the referring physician may have in the facility that the patient is being referred to;
• c) Provide the patient with the name and address of all applicable entities that the referring physician is an investor in; and
• d) Provide the names and addresses of at least two alternative facilities that can provide the requested referral services.

As of the date of this disclosure, no treating doctors at this facility have any financial interest in any other healthcare facilities that you may be referred to. The part owner of this medical facility, Dr. Gary Kompothecras, does have an investment interest in other medical facilities. Dr. Kompothecras, who is a Chiropractic Physician, does not treat patients at this facility, or make decisions regarding the referral services for its patients. Because Dr. Kompothecras is not engaged in treating patients, this disclosure requirement does not apply to them. Nonetheless, we have provided a list with this disclosure of all medical facilities that he currently has an investment interest in. If your treating doctor ultimately determines that you are in need of referral services and you wish to consider receiving treatment at a facility that he has an investment interest in, we will also provide, with this disclosure, the names and addresses of at least two other alternative facilities that can also provide the requested referral services, in addition to the names of any other facilities that you may obtain on your own.

Patient Acknowledgment: I hereby acknowledge that I have received a copy of the Physician Referral Patient Disclosure and Alternative Treatment Options

By my signature below, I hereby acknowledge that I have received a written disclosure identifying all entities that my health care provider (treating doctor) has an ownership interest in. I also acknowledge receiving a written disclosure by the owner of the facility where I am receiving treatment identifying all entities that he has ownership interest in as well. In addition to receiving a copy of the Related Facility Disclosure of Financial Interest and a Listing of Facilities with Common Ownership, I have also received a Listing of Alternative Facilities with No Common Ownership that can provide the same referral services. After review of the same, and consultation with my treating physician, I have decided to receive referral treatment at the following medical provider:

456.052 Disclosure of financial interest by production.

• (1) A health care provider shall not refer a patient to an entity in which such provider is an investor unless, prior to the referral, the provider furnishes the patient with a written disclosure form, informing the patient of:
  • (a) The existence of the investment interest.
  • (b) The name and address of each applicable entity in which the referring health care provider is an investor.
  • (c) The patient’s right to obtain the items or services for which the patient has been referred at the location or from the provider or supplier of the patient’s choice, including the entity in which the referring provider is an investor.
  • (d) The names and addresses of at least two alternative sources of such items or services available to the patient.
• (2) The physician or health care provider shall post a copy of the disclosure forms in a conspicuous public place in his or her office.
• (3) A violation of this section shall constitute a misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083. In addition to any other penalties or remedies provided, a violation of this section shall be grounds for disciplinary action by the respective board.

Surgery Consultants does not accept any health insurance, managed care, or Medicare or Medicaid for any medical care, services, supplies or procedures performed in the office, hospital, or an outpatient surgical center.

Your signature below acknowledges that Surgery Consultants, and its surgeons do not accept health insurance, managed care, or Medicare or Medicaid for any medical care, services, supplies or procedures performed in the office, hospital, or an outpatient surgical center. It is further acknowledged that Surgery Consultants, and its surgeons, are not obligated to bill any health insurance, managed care, or Medicare or Medicaid for any medical care, services, supplies or procedures performed in the office, hospital, or an outpatient surgical center. To the extent that you have entered into an irrevocable payment agreement with Surgery Consultants requiring otherwise, your signature below represents your agreement.

Prior to signing this document, I have had the opportunity to consider this decision and its effect on my medical bill, as well as my underlying personal injury claim. I understand that I have the option of having surgery with a surgeon who will accept my health insurance, managed care, or Medicare or Medicaid, if applicable. However, I choose to have my surgeon, employed by Surgery Consultants, perform the recommended care, treatment, inpatient or outpatient surgery.

The undersigned insured person (or guardian of such person) affirms:

• 2. I have the right and the duty to confirm that the services have already been provided.
• 3. I was not solicited by any person to seek any services from the medical provider of the services described above.
• 4. The medical provider has explained the services to me for which payment is being claimed.
• 5. If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid
• by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500.

Insured Person (patient receiving treatment or services) or Guardian of Insured Person:

The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and also:

• A. I have not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for Personal Injury Protection benefits.
• B. The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for that person to sign this form with informed consent.
• C. The accompanying statement or bill is properly completed in all material provisions and all relevant information has been provided therein. This means that each request for information has been responded to truthfully, accurately, and in a substantially complete manner.
• The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section 627.732 (15) and (16), Florida Statutes or Section 627.736(5)(b)6, Florida Statutes.

Licensed Medical Professional Rendering Treatment/Services or Medical Director, if applicable (Signature by his/ her own hand):