• Consent for Care. I recognize that I have a health care condition requiring care by a FOX VALLEY PULMONARY MEDICINE, S.C. (“FVPM”) health care professional and hereby voluntarily consent to customary examinations, tests, and procedures, including the use of topical and local anesthesia. I recognize that the practice of medicine is not an exact science and I acknowledge that no guarantees related to outcomes have been made or will be made to me.

• Medication History. I understand FVPM may obtain my medication history from community pharmacies and/or Pharmacy Benefit Managers for the purpose of continued treatment.

• Photo and Video Prohibition. To protect the privacy of all patients, photo or video recordings by the patient or any accompanying party within the patient care areas is strictly prohibited, unless authorized by the FVPM provider.

• Telephone Consumer Protection Act / Telephone and Email Communications. By supplying phone numbers (including my cell phone number), email address, and any other personal contact information, I authorize FVPM and its business associates to contact me at any of the numbers or email addresses, using an automatic telephone dialing system, pre-recorded voice, or other 3rd party automated outreach and messaging system, as well as to use my protected health information, or other personal or identifying information, during such contact for any administrative or healthcare matter. I consent to FVPM and its business associates contacting me via unencrypted email and text messages. I understand that (i) I am not required to give the foregoing consent as a condition of receiving medical care; (ii) message and data rates may apply; and (iii) I may revoke my consent to receiving such calls and/or messages at any time by contacting FVPM directly. I also agree that FVPM may leave detailed messages on my voice mail, answering system, or with another individual, if I am unavailable at the number provided by me. (To opt out of any of these communications, please indicate your specific instructions on the reverse side of this form.)

• Workers Compensation. In the event a workers compensation carrier denies my claim or service, and/or in the event my medical provider opines my condition is not related to my work injury claim, I agree to pay any and all applicable charges for services that are not covered by my insurance policy, including, but not limited to, charges that exceed my benefit level, co-payments, co-insurance, and/or deductible amounts.

• Financial Responsibility and Assignment of Benefits. I, the undersigned, authorize payment of medical benefits to FVPM for service(s) rendered. I understand I am financially responsible for any deductible, coinsurance, or amount not covered by my insurance. I agree to pay co-payments that my insurance company has included as part of my contract; at the time service is rendered. In the event I default on payment on my personal account balance and have failed to make reasonable payment arrangements, I understand the outstanding account balance will be assigned by FVPM to a third party for collection. I understand that unless I pay for services rendered to me by FVPM in full, out of pocket, and request that the information not be released, FVPM may release to my insurance or workers’ compensation carrier any information or diagnoses and records of any treatment needed for the purpose of determining benefits for payment of services rendered to me.

• Medicare Authorization (if applicable). I request that payment of authorized Medicare benefits be made on my behalf to FVPM for any services furnished to me. I understand that FVPM accepts Medicare assignment and agrees to accept the charge determination for the Medicare carrier as the full charge and I am responsible for co-insurance, deductible, and non-covered services. I understand that co-insurance and deductibles are based on Medicare charge determination.