MEDICARE / MEDI-CAL / PRIVATE / HMO

I request that payment of authorized Medicare and or other insurance carrier benefits be made on my behalf to Nephrology Associates Medical Group, Inc. (NAMG) for any services furnished to me by that Physician. I authorized you to release any medical information about me that needed to determine these benefits or the benefits payable to related services to the Health Care Financing Administration and or my other insurance carrier and its agents.

I understand my signature requests that payments be made directly to the physician and authorize the release of medical information necessary to pay the claim. If item 9 of the HCFA-1500 claim form is completed, my signature authorizes releasing of the information to the insurer or agency shown, and Medicare carrier for the full charge. I understand the coinsurance and deductibles are based upon the charge determined to the Medicare carrier.

Financial Responsibility

I do hereby accept financial responsibility for all charges incurred by me. I understand that I am responsible for any charges not covered by my insurance companies and agree to provide a referral for each visit, pay any co-payments, Medi-cal share of costs, or annual deductibles that apply. I also understand that ifl fail to provide Nephrology Associates Medical Group, Inc. with the necessary information to bill my insurance company or fail to inform them of any changes in my insurance coverage, that I will be billed and held liable for the changes.

Authorization to Obtain or Release o(Medical Records from Medical Providers

I hereby authorize any of the above physicians to obtain all medical records concerning my care from any physician, hospital or other health care professional that has provided medical care to me in the past.

I also authorize the practice to release all medical records concerning my care to any physician, hospital or other health care professional providing care to me at any time. Additionally, I authorize the practice to authorize al medical records concerning care to Medicare, Medicaid, any insurance company, third party administrator, or managed care company.

Authorization to Release Medical Information to Individuals/ Family Members

In accordance with the Federal Government Privacy rules implemented through the Healthcare Portability Act of 1996 (HIPPA), In order, for your physician or staff of the practice to discuss your condition with members of your family or other individuals that are designate, we must obtain your authorization prior to doing so. In the event of a critical episode or if you are unable to give authorization due to severity of your medical condition, the law stipulates that these rules may be waived.

Acknowledgement of Receipt of Notice of Privacy Practices

I hearby acknowledge that I received a copy of Nephrology Associates Medical Group, Inc.\'s Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment.

24 Hour Cancellation & "No Show" Fee Policy

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Therefor, Nephrology Associates Medical Group, reserves the right to charge a fee of $50 for all missed appointment such as, No Show for New Patient consultations and $25 for all Follow Up missed appointments for established patients. Please be aware that this bill will be sent to patient since insurance does not cover this fee and must be paid prior to your next appointment.

Thank you for your understanding and cooperation as we strive to best serve the needs of our patients.

By signing below, you are acknowledging that you have received this notice and understand the policy.