BY INITIALING THIS SECTION, YOU ACKNOWLEDGE THIS INFORMATION IS AN ESTIMATE OF BENEFITS AND NOT A GUARANTEE OF PAYMENT. YOU ARE RESPONSIBLE FOR ALL TREATMENT RELATED FEES BASED ON YOUR CONTRACTUAL AGREEMENT WITH YOUR INSURANCE COMPANY EVEN IF THE EVENT YOUR BENEFITS WERE MISQUOTED TO US.

C. Payment for Services

. Patient shall be fully responsible for all payments of services, including but not limited to deductible, co-insurance, co-payments, equipment, supplies, and charges not paid for, whether in part or as a whole, by insurance per Patient’s insurance benefits. Patient’s total unpaid balance for all services, deductible, co-insurance, co- pay amounts, and any unpaid equipment and supply charges (not paid at the time of issue) are subject to XPT&WC’s collection policy.

XPT&WC’s Collection policy is: All insurance claims responsible must be paid in full within Sixty (60) days following the date your insurance company receives a clean claim. Upon claim processing and starting the 61st day from the first statement date, should the Patient or legally designated representative fail to pay XPT&WC the full amount due per XPT&WC’s policy, a late fee equal to ten percent (10%) of the amount due shall be added to the claim balance. Additionally, starting on the 61 st day the claim is outstanding until the debt is fully settled, interest shall accrue on all past-due amounts at ten percent (10%) per annum (compounded monthly). In the event of an over-payment, XPT&WC shall have thirty (30) days following the posting of the applicable processed claim to refund the over-payment

D. Credit Card Authorization

In the event the open claim balance has not been satisfied on the sixty first (61st) day from submission to the insurance company, or in the event any check used for payment by Patient is returned or declined due to insufficient funds, XPT&WC is hereby authorized to charge my credit card on file in an amount equal to the full open claim balance. All approved written payment plans are null and void if your Credit Card payment is not approved and payment cannot be collected within twenty-four (24) hours via valid Credit Card _________ (Initial)

Deductibles, co-pays, co-insurance, equipment, and supplies ARE DUE IN FULL AT THE TIME OF SERVICE. As a courtesy to you, we can automatically charge your card the estimated patient responsibility for each visit based on the estimated benefits quoted by your insurance company. Please acknowledge by initialing that you request XPT&WC to automatically charge your credit card on file for each date of service. _________ (Initial)

Once your claims have been processed, we can determine your exact responsibility. Necessary adjustments to the amount due will then be made. If an overpayment has been made, you will be promptly refunded. Additionally, we will use your credit card to process any cancellation or no-show fees. If you prefer to provide alternate payment or slide your credit card at every appointment, we will then only use your credit card on file to satisfy any remaining fees due after claims processing, at the end of your treatment or on the 61st day from submission to the insurance company, whichever is sooner. All approved written payment plans are void if your Credit Card payment is not approved and payment cannot be collected within twenty-four (24) hours via valid Credit Card. In the event there is no credit card on file, Patient acknowledges they may be discharged from care of the provider until such time as Patient’s account is brought current

E. Patient Discharge/Collections Fees

In the event Patient fails to pay for services rendered, Patient understands that Patient may be discharged from the services of Provider until such time as Patient’s account is paid in full. Patient understands and agrees: Failure to maintain a current account may result in suspension or discharge from care. Provider will make reasonable efforts to notify Patient prior to discharge, consistent with clinical judgment and applicable standards. Patient may resume care once account is brought current, subject to Provider availability. Patient accepts responsibility for any consequences resulting from interruption of care due to non-payment.

Additionally, Patient understands that Patient may be referred to a collection agency for non-payment of fees due for services rendered by Provider. Patient understands and agrees that Patient will be responsible for all collection, agency, and/or attorneys’ fees, as well as all costs associated with the collection process (including but not limited to Court costs), and that these fees and costs will be added to Patient’s account balance. Moreover, Patient understands and expressly agrees that Patient’s Personal Health Information (“PHI”), as regulated by HIPAA, may be revealed in an effort to collect all past due outstanding balances.

F. Returned Check Fee

Patient understands that in the event a check used for payment is returned due to insufficient funds, Patient agrees to provide, within twenty-four (24) hours of notice, cash, money order, or certified check for the full amount of the payment owed, in addition to a $50.00 returned check charge. If Patient makes no secondary payment per the terms herein, then Patient hereby authorizes Provider to charge Patient’s Credit Card the outstanding amount per the terms of Section “E,” hereto

G. Assignment of Benefits

Patient hereby authorizes assignment and/or payment of all Benefits, which are payable to Patient under the terms of Patient’s Coverage, to be assigned and/or paid directly to XPT&WC for services rendered, as provided by California State and/or federal prompt pay rules, regulations, and statutes. Patient further consents to the use and disclosure of PHI or any other relevant personal information for the purposes of treatment, payment, and general operations, including but not limited to the processing of all insurance claims. XPT&WC courtesy billing service is limited to billing primary and secondary insurance carriers; all other insurance claims are the patient’s responsibility to file. I understand I am responsible for any costs incurred by XPT&WC to adjudicate my claims. Lastly, I understand that I, my heirs and/or assignees are fully responsible for any outstanding charges, including charges for equipment and supplies not paid by my insurance.

Patient understands that should Patient’s insurance company send payment directly to Patient, Patient will either immediately forward the actual checks, endorsed to XPT&WCP.C., or provide XPT&WC the exact amount of the insurance payment by check or cash within seven (7) days of Patient having received such insurance payment, which hereby belongs to XPT&WC

Patient agrees that in the event Patient fails to satisfy claim balance(s) upon cashing any applicable insurance checks, the claim balance(s) can be paid by credit card, subject to the terms of Section E, hereto. Patient hereby authorizes XPT&WC to charge the credit card on file in the amount necessary to satisfy the entire unpaid claims balances including a three percent (3%) pass- through credit card service fee. __________ (Initial)

Note: Cashing check(s) with the intention of defrauding XPT&WC may be considered a crime.

H . Missed Appointment Fee

I understand that I will be assessed a $50 fee if I miss a scheduled appointment without having provided a twenty-four (24) hour advance notice of cancellation. We understand that from time to time there may be circumstances that require you to cancel with less than 24 hours’ notice. We will determine the fee assessment on a case-by-case basis. Because we do not overbook, giving us as much notice as possible allows us to try to fill your appointment, thereby simply allowing us to waive your fee. “No-Showing” will ALWAYS result in a missed appointment fee assessment. _________ (Initia)

I . Out-of-Network Responsibilities

XPT&WC agrees to accept the amount paid for claim reimbursement when the insurance payer considers XPT&WC an “Out of Network Provider,” so long as the amount paid is an accurate payment for the services rendered. Further, the Patient’s Out-of-Pocket financial responsibility to XPT&WC will be limited to the amount equal to the Patient’s financial responsibility for In-Network providers.

J .

This contract shall be governed by the laws of the County of Ventura in the State of California and all applicable federal la ws. In witness of their agreement to the terms above, the parties or their authorized agents hereby affix their signatures:

Credit Card Authorization Form for Services Rendered at Xcel Physical Therapy & Wellness Center, P.C.

(Debit cards may be used if they have a major credit card logo.)