AccelHealth Consent to Treatment

Please read form in its entirety and ask staff any questions prior to signing.

General Consent

I give permission to AccelHealth, its designated staff, and other medical, dental, mental or behavioral health, and social service personnel
providing services, case management, and counseling under its sponsorship to provide services as indicated by license and or title, including
physical, dental, and or mental or behavioral health assessments or examinations, conduct laboratory or other tests, which may include HIV
testing, give injections, medications, and other treatment as appropriate, and render any other physical, dental, or mental health services to
the patient identified on this form.

Informed Consent for Telemedicine and or Telehealth

Telehealth and telemedicine services are health care services delivered by physicians and health professionals to patients located at a different
physical location using telecommunications or other information technology. Telecommunications or other information technology may also be used
for virtual check-ins, e-visits, initial evaluations, screenings, and pre and post visit communication by AccelHealth staff.

I understand the same standard of care applies to health care services delivered via telemedicine and or telehealth as applies to an in-person
visit.

I will not be physically in the same room as my healthcare provider.

I will be notified of, and consent obtained for, anyone other than my healthcare provider present in the room.

I understand there are certain hazards and risk connected with all forms of treatment, regardless of the medium used, and my consent is given
knowing potential risk using technology, including service interruptions, interception, and technical difficulties.

If it is determined the telecommunications or information technology is not adequate, the visit may be discontinued.

I have the right to refuse to participate or decide to stop participating in a telemedicine or telehealth visit at any time.

AccelHealth has no liability or responsibility for the accuracy or completeness of the medical information submitted to them or for any errors
in its electronic transmission.

Information shared using telecommunications may include patient medical records, medical images, medical audio or video files, two-way audio
and video, and output data from medical devices. The systems used by the center to transmit and receive this information will incorporate
network and software security protocols intended to protect the confidentiality of the patient’s identity and information.

Release of Medical, Dental, and Mental Health Information

I hereby give permission for medical, dental, and mental or behavioral health information obtained by AccelHealth to be released to other health
care providers as is necessary for referral purposes only. I furthermore understand that AccelHealth uses electronic records and these records
are shared within staff providing services.

Payment Policy

It is my responsibility to confirm that the physician, dentist, or clinician is a covered provider under my insurance plan. I hereby authorize
the assignment of benefits payments directly to AccelHealth (Cross Timbers Health Clinics, Inc.) for all my insurance claims related to services
received. I understand that I am financially responsible for services provided which are to be paid on the day services are rendered. This
includes co-payments, deductibles with any managed care contract, and non-covered services.

The statement below is for patients who have insurance:

I authorize the release of any medical, dental, and or mental or behavioral health information necessary to process reimbursement for treatment
services and request payment of Medicare, Medicaid, or any other third party reimbursement, public or private, for which I may be eligible.

For Medicare and Medicaid

I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. Photocopy shall be
valid as an original. I request that payment of authorized Medicare and or Medicaid benefits be made on my behalf to AccelHealth (Cross Timbers
Health Clinics, Inc.) for any services furnished to me by the providers of this group. I authorize any holder of medical information about me
to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits
payable for related services.

I understand that my signature authorizes requests for payment as well as release of any medical information necessary for CMS or the Medicaid
payer to pay the claim. I also acknowledge that AccelHealth agrees to accept the charge determination of the Medicare carrier as the full charge
and I agree to be responsible only for the deductible, coinsurance, or non-covered services. Coinsurance and deductible amounts are based on
the charge determination of the Medicare carrier. The clinic agrees to accept Medicaid payments in accordance with Medicaid regulations as
payment in full.

Medigap Release

For Medicare patients with supplemental Medigap insurance, a separate signature is needed. I request Medigap benefits be made on my behalf
for services rendered. I authorize release to my Medigap carrier any information needed to determine benefits.

Acknowledgment of Received Documents

I acknowledge receipt of the following documents:

• Welcome to AccelHealth
• PCMH, Your Medical Home
• Patient Rights and Responsibilities
• HIPAA Notice of Privacy Practices
• Financial Policy

By your signature below, you certify that this form was fully explained to you and that any questions you have about services have been
answered to your satisfaction and documents were received. This informed consent is valid and remains in effect as long as I am a patient for
AccelHealth, until I withdraw my consent, or until the center changes its services and asks me to complete a new consent form.

Patient Information

Patient First Name: *

Patient Last Name: *

Signature of Patient, Guarantor or Guardian (Please Type): *

Date: *