Consent to Telemedicine

I hereby consent to the use of telemedicine by Rume Health, and contracted medical groups including “Elevated Health” and “Rume Medical Group”. I understand that telemedicine involves the communication of my medical information, both orally and visually , to providers involved in my treatment who are located at a different site than me. I understand I have all of the following rights with respect to telemedicine:

Patient Choice. I have the right to withhold or withdraw my consent to telemedicine at any time without affecting my right to future treatment. Access to Information. I have the right to inspect and receive copies of all medical information transmitted durin g a telemedicine consultation. I understand that my telemedicine provider will communicate my relevant health information to physicians and other health care practitioners involved in my treatment who are located in different offices or clinics in the state, such as my primary care physician or therapist.

Confidentiality. I understand that the laws which protect the confidentiality of medical information apply to telemedicine, that I will not be recorded, and that no information from my telemedicine consultations that identifies me will be disclosed to third parties without my consent. Potential Risks. I understand that there are potential risks associated with telemedicine, including disruption or d istortion in the transmission of medical information and unauthorized access to medical information generated, transmitted, and stored pursuant to the telemedicine consultation. I understand that telemedicine is an alternative to in-person treatment and my Elevated Health/Rume Medical Group provider may recommend I discontinue telemedicine and receive in-person treatment in certain circumstances. I understand that telemedicine does not negate or minimize the risks that may be inherent to my illness or condition and that there may be other risks associated with telemedicine that are not listed here.

Benefits. I understand that I can expect benefits from telemedicine, but that no particular results can be guaranteed.

Statement of Financial Responsibility

Thank you for choosing Rume Health as your provider. We are committed to providing you with the best possible care. Your clear understanding of our practices’ financial policy is important to our professional relationship. We make every effort to keep our fees reasonable while at the same time covering the cost of the services we provide. Payment of your bill is considered part of yo ur overall treatment and responsibility. In order to keep healthcare costs to an absolute minimum, we have adopted the following policies.

Fees and Payments

Fees are standard and based on the complexity of your visit. Payment in full is required at the time of your visit and can be made with cash, personal check, money order, Visa, MasterCard, or Discover.

While filing insurance claims is a courtesy that we extend to all of our patients, all charges are your responsibility from the date services are rendered. Rume Health will file claims to insurances provided (primary & secondary) during registration. Your insurance is a contract between you and/or your employer, and the insurance company, we are not party to that contract. In order for us to file a claim on your behalf, you must present a CURRENT copy of your insurance card(s) at each visit and communicate any changes in your personal information.

Not all services are a covered benefit in all policies, so it is very important that you understand the provisions of your individual policy. Insurance companies select certain services that they will not cover, therefore we can’t guarantee payment of all claims by your insurance company. Some common examples of non-covered services are labs, radiology, pharmacy, dental supplies and/or labs, contact lenses, mental health, and chiropractic, etc. Rejection of your claim does not relieve you of your financial responsibility to Rume Health “Elevated Recovery / Rume Medical Group Inc.”

PLEASE NOTE: Each visit is documented in your medical record and a diagnosis is made by the provider. Diagnoses are made based on medical information, not based on coverage by insurance companies. To request a diagnosis, change solely for the purpose of securing reimbursement from an insurance carrier is inappropriate and is considered insurance fraud.

Required at Check-in:

I. Verify personal contact information
II. Present current copy of insurance card III. Present current picture ID IV. Payment of any outstanding balance V. Payment for today’s visit

Medicare and Medi-Cal

We gladly accept Medicare patients and will bill our services at the allowed rates. Medicare regulations require that you sign an Advanced Beneficiary Notice (ABN) at every visit where your procedure may not be covered. This form helps to explain which se rvices Medicare may not cover and may be your responsibility. Non-Covered services include, but are not limited to, Chiropractic and Vision.

Co-Payments

Your insurance company requires us to collect copayments at the time of service. Waiver of copayments may constitute fraud un der state and federal law. If you do not have your co- payment, your appointment may be rescheduled.

Medical Records

All Rume Health patients may request a copy of their medical records via email. This can be done at no charge to the patient and received electronically within 30 (thirty) business days.

MISCELLANEOUS CHARGES:

Collection Charge

Accounts that are not paid within 90 days from the date of service may be sent to an external collection agency and reported to one or all national credit bureaus. In addition to your outstanding balance, a 33% surcharge may be added to cover our costs. In addition, you may be removed from the practice.

Refunds

Cases involving implantable items will be assessed on an individual basis. Any accounts that have outstanding claims will not be eligible for a refund.

As record of disclosure:

I. We have made prior arrangements with many insurance carriers to accept an assignment of benefits. This means we will bill contracted insurance plans and will hold you responsible for the portion the carrier assigns as your responsibility (deductib les, coinsurance, co-pay, non- covered services). We accept behavioral health, and medical plans. The type of service you receive will dictate which type of insurance we bill. All billable services are usually sent to the medical plans.

II. Advance Beneficiary Notice of Non-coverage (ABN), also known as a waiver of liability, is a notice you will receive and sign when you

are planning to receive services or treatment that we believe Medicare will not cover. This will serve as a warning th at Medicare may not pay for your treatment, but you are agreeing to pay for the services if Medicare rejects the coverage.

III. A credit card on file will be used to secure any outstanding balances owed to Rume Health. after your insurance plan has paid their portion. This may also be used for deductibles, copayments and arrangements established between you and our finance department. This process allows Rume Health. to resolve open balances in a timely manner.

IV. We will not become involved in disputes between you and your insurance carrier regarding deductibles, co - payments, non-covered charges, etc. We will, however, make certain advanced authorization requests to alleviate as many non-covered fees as possible. Your insurance policy, however, is a contract between you and your carrier. Contact your insurance representative and understand y our coverage and benefits prior to undergoing any service/procedure.

Uses and Disclosure of Health Information

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

REVIEW IT CAREFULLY This notice is effective as of April 15, 2023 USES AND DISCLOSURE OF HEALTH INFORMATION

Rume Health is committed to protecting the privacy of the personal and health information we collect or create as part of providing health care services to our clients, known as “Protected Health Information” or “PHI”. PHI typically includes your name, address, date of birth, billing arrangements, care, and other information that relates to your health, health care provided to you, or payment for health care provided to you. PHI DOES NOT include information that is de-identified or cannot be linked to you.

This notice of Health Information Privacy Practices (the “Notice”) describes Rume Health’s duties with respect to the privacy of PHI, Rume Health’s use of and disclosure of PHI, client rights and contact information for comments, questions, and complaints.

Rume Health’s PRIVACY PROCEDURES AND LEGAL OBLIGATIONS

Rume Health obtains most of its PHI directly from you, through care applications, assessments, and direct questions. We may c ollect additional personal information depending upon the nature of your needs and consent to make additional referrals and inquiri es. We may also obtain PHI from community health care agencies, other governmental agencies, or health care providers as we set up your service arrangements.

Rume Health is required by law to provide you with this notice and to abide by the terms of the Notice currently in effect. Rume Health reserves the right to amend this Notice at any time to reflect changes in our privacy practices. Any such changes will b e applicable to and effective for all PHI that we maintain including PHI we created or received prior to the effective date of the revised notice. Any revised notice will be mailed to you or provided upon request. Rume Health is required by law to maintain the privacy of PHI. Rume Health will comply with federal law and will comply with any state law that further limits or restricts the uses and disclosures discussed below. In order to comply with these state and federal laws, Rume Health has adopted policies and procedures that require its employees to obtain, maintain, use and disclose PHI in a manner that protects client privacy.

USES AND DISCLOSURES WITH YOUR AUTHORIZATION

Except as outlined below, Rume Health will not use or disclose your PHI without your written authorization. The authorization form is available from Rume Health. You have the right to revoke your authorization at any time, except to the extent that Rume Medical Group Inc has taken action in reliance on the authorization.

The law permits Rume Health to use and disclose your PHI for the following reasons without your authorization:

For Your Treatment: We may use or disclose your PHI to physicians, psychologists, nurses and other authorized healthcare professionals who need your PHI in order to conduct an examination, prescribe medication or otherwise provide health care ser vices to you.

To Obtain Payment: We may use or disclose your PHI to insurance companies, government agencies or health plans to assist us in getting paid for our services . For example, we may release information such as dates of treatment to an insurance company in order to obtain payment.

For Our Health Care Operations: We may use or disclose your PHI in the course of activities necessary to support our health care operations such as performing quality checks on your employee services. We may also disclose PHI to other persons not in Rume Health's workforce or to companies who help us perform our health services (referred to as "Business Associates") we require these business associates to appropriately protect the privacy of your information.

As Permitted or Required By The Law: In some cases we are required by law to disclose PHI. Such disclosures may be required by statute, regulation court order, or government agency; we reasonably believe an individual to be a victim of abuse, neglect or domestic violence: for judicial and administrative proceedings and enforcement purposes.

For Public Health Activities: We may disclose your PHI for public health purposes such as reporting communicable disease results to public health departments as required by law or when required for law enforcement purposes.

For Health Oversight Activities: We may disclose your PHI in connection with governmental oversight, such as for licensure, a uditing and for administration of government benefits.

To Avert Serious Threat to Health and Safety: We may disclose PHI if we believe in good faith that doing so will prevent or lessen a serious or imminent threat to the health and safety of a person or the public.

Disclosures of Health Related Benefits or Services: Sometimes we may want to contact you regarding service reminders, health related products or services that may be of interest to you, such as health care providers or settings of care or to tell you about other health related products or services offered at Rume Health. You have the right not to accept such information.

Incidental Uses and Disclosures: Incidental uses and disclosures of PHI are those that cannot be reasonably prevented, are limited in nature and that occur as a by-product of a permitted use or disclosure. Such incidental uses and disclosures are permitted as long as Rume Health uses reasonable safeguards and use or disclose only the minimum amount of PHI necessary.

To Personal Representatives: We may disclose PHI to a person designated by you to act on your behalf and make decisions about your care in accordance with state law. We will act according to your written instructions in your chart and our ability to verify the identity of anyone claiming to be your personal representative.

To Family and Friends: We may disclose PHI to persons that you indicate are involved in your care or the payment of care. These disclosures may occur when you are not present, as long as you agree and do not express an objection. These disclosures may also occur if you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest. We may also disclose limited PHI to a public or private entity that is authorized to assist in disaste r relief efforts in order for that entity to locate a family member or other person that may be involved in caring for you. You have the right to limit or stop these disclosures.

YOUR RIGHTS CONCERNING PRIVACY
Access to Certain Records: You have the right to inspect and copy your PHI in a designated record set except where State law may

prohibit client access. A designated record set contains medical and billing and case management information. If we do not have your PHI record set but know who does, we will inform you how to get it. If our PHI is a copy of information maintained by another health care provider, we may direct you to request the PHI from them. If Rume Medical Group Inc produces copies for you, we may charge yo u up to $1.00 per page up to a maximum fee of $50.00. Should we deny your request for access to information contained in your designated record set, you have the right to ask for the denial to be reviewed by another healthcare professional designated by Rume Hea lth.

Amendments to Certain Records: You have the right to request certain amendments to your PHI if, for example, you believe a mistake has been made or a vital piece of information is missing. Rume Health is not required to make the requested amendments and will inform you in writing of our response to your request.

Accounting of Disclosures: You have the right to receive an accounting of disclosures of your PHI that were made by Rume Health for a period of six (6) years prior to the date of your written request. This accounting does not include for purposes of treatment, payment, health care operations or certain other excluded purposes, but includes other types of disclosures, including disclosures for public health purposes or in response to a subpoena or court order.

Restrictions: You have the right to request that we agree to restrictions on certain uses and disclosures of your PHI, but we are not required to agree to your request. You cannot place limits on uses and disclosures that we are legally required or allowed to make.

Revoke Authorizations: You have the right to revoke any authorizations you have provided, except to the extent that Rume Health has already relied upon the prior authorization. Delivery by Alternate Means or Alternate Address: You have the right to request that we send your PHI by alternate means or to an alternate address.

Complaints & How to contact us: If you believe your privacy rights have been violated, you have the right to file a complaint by contacting Rume Health at the address and/or phone number indicated below. You also have the right to file a complaint with the Secretary of the United States Department of Health and Human services in Washington, D.C. Rume Health will not retaliate against you for filing a complaint.

If you believe your privacy rights have been violated, you may make a complaint by contacting customer service at 855-932-7263 (SAME) or the Secretary for the Department of Health and Human Services. No individual will be retaliated against for filing a complain t.

The U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Washington, D.C. 20201 Toll Free: 1-877-696-6775 Please be aware that mail sent to the Washington D.C area offices takes an additional 3-4 days to process due to changes in mail handling resulting from the Anthrax crisis of October 2001.

RESTRICTION REQUEST: I request a restriction on the Use or Disclosure of my following information: n/a

Release of Responsibility

I hereby acknowledge and agree to the following:

Responsibility for Follow-Up Care: I understand that it is my responsibility to follow through and end any referred follow-up care, consultations, or treatments as recommended by my provider. I am aware that failure to end these appointments may result in n egative health consequences.

Provider's Limitation of Responsibility: I acknowledge that once a referral has been made, the responsibility of ensuring attendance and completion of the follow-up care, consultations, or treatments lies solely with me, and it is not the responsibility of the referring provider.

Communication: I understand that I should maintain open communication with any referred specialists or healthcare providers and relay any pertinent health information or updates to them.

Potential Risks: I recognize that neglecting to attend recommended follow-up care may increase the risk of complications, poor outcomes, or progression of my health condition. I accept these risks and any consequences that may arise due to my failure to attend referred appointments.

Acknowledgment of Understanding: I have read (or had read to me) the above information, and I have had the opportunity to ask questions. I understand the information provided and agree to assume responsibility for my referred follow-up care.

I understand if I should leave the facility preemptively while I have pending laboratory or imaging orders, the facility will do their due diligence to reach out to me at the number and email listed on file. However, it is my responsibility to reach out to RUME medical group at 855-932-7263 (SAME) should I have an interruption in my contact information, and they are not able to reach me. Rume providers and RUME medical group are absolved of any liability should the patient preemptively leave and are not able to be reached per above.

I acknowledge my understanding and agreement with the above statements.

Release of Medical Records

Authorization for Use and Disclosure of Health information

I authorize Rume Health to disclose of medical records to my treating facility and any referring providers needed for my medi cal care.

YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:

1. I understand that by agreeing to this authorization, I will be provided with a copy of this authorization upon request.

2. I understand that I am under no obligation to give authorization and that Rume Health, Inc providers may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on my decision to sign this authorization except regarding health plan enrollment or eligibility, or the provision of health care that is solely for the purpose of creating PHI for dis closure to a third party.

3. I understand that I have the right to withdraw this authorization at any time by providing a written statement of withdrawal to Rume Health. I am aware that my withdrawal will not be effective until received by Rume Health, Inc and will not be effective regarding the uses and/or disclosures of my health information that Rume Health has made prior to receipt of my withdrawal statement.

REDISCLOSURE NOTICE: I understand that information used or disclosed based on this authorization may be subject to re-disclosure and no longer protected by Federal privacy standards.

THIS AUTHORIZATION IS VALID FOR ONE YEAR (12 MONTHS) FROM DATE OF AGREEMENT