CONSENT TO MEDICAL CARE AGREEMENT AND RELATED DISCLOSURES

Thank you for seeking care from Live Life Now Health powered by Monument, Inc., (“Live Life Now Health”). This Consent to Medical Care Agreement establishes a clinical relationship between Live Life Now Health, as your provider and you as the patient and authorizes Live Life Now Health to provide you medical care, share your health information, and receive payment for the service provided. Other than in the case of an emergency, you must sign this form prior to any treatment.

Our Notice of Privacy Practices describes how we may use or disclose your Protected Health Information (PHI). By initialing the boxes below, you agree to have reviewed our notice and give consent to the following uses and disclosures.

Consent to Treatment:

I consent to receive medical and health care services provided by Live Life Now Health’s physicians, employees, and other providers as my physicians deems necessary.

“Other Providers” include, but are not limited to, physicians and other healthcare providers and any allied healthcare providers whom these physicians utilize. Some of the physicians and their allied healthcare providers are independent medical practitioners who are not employees or agents of Live Life Now Health, but who are permitted to use Live Life Now Health hospital facilities for the care and treatment of their patients. Live Life Now Health hospitals do not control or direct a physician’s care of his or her patients.

I consent to diagnosis, medical care and treatment that I have agreed to receive and that is considered necessary or recommended by my provider(s), including treatment and services through the use of Live Life Now Health’s telehealth technologies, such as in person communications, telephone calls, instant messages or text messages, and any video conferencing or other virtual care. I agree that Live Life Now Health can create recordings and images containing my health information for treatment, education and Live Life Now Health operations as described in the Live Life Now Health Notice of Privacy Practices.

Release of Medical and Personal Information

Medical Information

I acknowledge that Live Live Now Health may use health information exchange systems to electronically transmit, receive, and or access my medical Live Life Now Heath may collect the following information:

• diagnostic information
• lab tests
• current medications and medication history
• allergies
• medical history
• treatment plans
• progress or presence in treatment
• clinical notes
• discharge summaries and other records pertaining to my treatment.

If I am a pregnant patient, I understand that Live Life Now Health may use and release my health information for the care and treatment of my newborn child/children, for related payment and operations. I understand that my health information will be included in my newborn child/children’s medical records.

My care provider may take photographs, video, audio, or otherwise capture images that may be used only for the purposes of medical care, education, performance improvement, de-identified research, and such other purposes permitted by law. Live Life Now Health may also use photography, biometrics and/or videotaping to facilitate my registration and for my identification as a patient. Live Life Now Health will protect the confidentiality of my images in accordance with all applicable Federal and state privacy laws.

Additional Medical Consents

Re-Disclosure Consent

I also agree that Live Life Now Health may further re-disclose, as allowed by HIPAA, my sensitive health information (1) to regulators for required disease or other state law reporting; and (2) to non-Live Life Now Health providers for their treatment, payment and healthcare operations purposes. Non-Live Life Now Health providers may include providers participating with Live Life Now Health in programs allowing for the exchange of health information between providers for purposes of treating me or coordinating care. I may opt out of re-disclosure of my information by contacting support@joinmonument.com.

Prescription and Medication Consent

I understand that Live Life Now Health may request, use, or disclose my prescription medication history with other healthcare providers and/or third party pharmacy benefit managers for my treatment purposes or to share prescription information to determine which medications are covered by my drug benefit plan.

Personally Identifiable Information (PII)

I acknowledge that Live Live Now Health may use the following personally identifiable information to provide further treatment, research, allow for providers to communicate with me directly, and other services as dictated by law:

• First name
• Middle name
• Last name
• Phone number
• Email address

I agree that all telephone numbers and email addresses I provide to Live Life Now Health may be used by Live Life Now Health or those acting on its behalf to communicate with me by telephone (including cell phone), text, email, or any automated or prerecorded messages. If I do not want to receive text messages or phone calls, then I can email support@joinmonument.com and ask to be removed from the list.

Telemedicine (Remote Services) Consent

I understand that Live Life Now Health and its affiliated providers will provide its services primarily by remote methods like video conferencing also known as Telemedicine services. Telemedicine services involve a provider who is at a site remote from my location at the time of the service, and may require the transmission of video, audio, images, or other types of electronic data about my condition. The types of activities permitted using telemedicine services include consultation, diagnosis, treatment, prescriptions, and patient education. The remote health care provider will determine whether the condition being diagnosed or treated is appropriate for telemedicine.

I give my authorization and consent for my treating providers at the Live Life Now Health to exchange information with other remote health care providers to facilitate the provision of telemedicine services. I understand that Live Life Now Health uses security measures such as encryption and authentication techniques to protect electronic information stored or transmitted during telemedicine services, but that there may be potential risks to privacy notwithstanding such measures. I agree to hold Live Life Now Health harmless for information lost due to technical failures, hacking, or other data intrusions to the extent permitted by law. Lastly, I acknowledge that no guarantees have been made regarding the effect of any care or treatment, whether in-person or using telemedicine technology, on any medical condition.

Right to Withdraw Consent:

I understand that I can withdraw my consent at any time. I agree that the consents and permissions as described in consent apply to all my sensitive health information in Live Life Now Health’s possession, including information concerning care received prior to or after the date of this form. I understand that I may withdraw my consent at any time by providing written notice to Live Life Now Health either via email at support@joinmonument.com or mail at Monument, Inc 350 7th Ave, Suite 600, New York, NY 10001.

If I withdraw my consent, I understand that Live Life Now Health will not use or disclose my sensitive information (unless otherwise allowed by law). I also understand, however, that if I withdraw my consent, my withdrawal will not apply to any uses and releases of my health information already made by Live Life Now Health before I changed my consent choice or, other than described above, to any health information that has become part of my record before I changed my consent choice. I understand that I have the right to inspect and copy any of my sensitive health information to be used or disclosed.

FINANCIAL CONSENTS AND ACKNOWLEDGMENTS

agree I am financially responsible for and agree to pay Live Life Now Health for services, supplies and use of facilities to provide my medical care and understand Live Life Now Health will charge me at the applicable rate for the medical care I receive. If I choose to have my health insurance reimburse Live Life Now Health for my medical care, I give permission to Live Life Now Health to bill any such insurer and update that information as necessary. I understand that insurance coverage varies and that my insurer may not pay for everything or may pay only part of my bill. If my insurer has an agreement with Live Life Now Health, then except for any applicable co-payments, coinsurance or deductibles, I will not be responsible for charges over the rate my insurer and Live Life Now Health have agreed upon. I understand that my insurer may deny payment for services that the insurer decides are not “medically necessary” or that are “experimental.” While Live Life Now Health will take reasonable steps to appeal these denials, I understand that I am responsible for paying for services denied by my insurer. If I choose to have Live Life Now Health bill my health insurance to pay for my treatment, I assign to Live Life Now Health my rights to receive payment from my health insurer or plan or any applicable settlements or judgements. If my insurance benefits are provided through an ERISA plan, I hereby assign, transfer and set forth all my rights, title and interest as a beneficiary of the ERISA plan to Live Life Now Health, with regard to my treatment and care. I also appoint Live Life Now Health as my authorized representative and grant Live Life Now Health limited power of attorney to receive plan coverage information and appeal any rights to payment and healthcare benefits. I agree to cooperate and provide information as needed by Live Life Now Health to establish my eligibility for my insurance benefits, including providing Live Life Now Health with any updates to my insurance coverage. If I claim benefits under Title XVIII of the Social Security Act (Medicare), I hereby certify that the information I provide in applying for payment of such benefits is correct, and I authorize Live Life Now Health to release to the Social Security Administration, its intermediaries or carriers any information needed for this or any related Medicare claim. Even though I may assign my right to receive payment from my insurer, I understand and agree that Live Life Now Health may still require payment directly from me.

As required by the Fair Patient Billing Act, I understand:

• I may receive separate bills from Live Life Now Health providers for the services provided to me.
• All providers may not participate in the same insurance plans and networks. Services provided by non-participating providers in an insurance plan or network are defined as “out-of-network services.” I understand that I may have greater financial responsibility for out-of-network services. I understand that it is my responsibility to contact my insurance company to determine whether Live Life Now Health is a participating provider in my insurance plan or network.
• Any questions I have regarding my health insurance coverage or benefit levels should be directed to my health plan, my employer or my insurance certificate of coverage. Live Life Now Health cannot guarantee that a service will be covered under my plan.

I understand that if I make an appointment, but do not attend that appointment (“No show”) and I do not cancel such appointment with 24 hours prior notice, Live Life Now Health may charge me a No show fee.

I acknowledge that I have been provided the Live Life Now Health policies applicable to my care and have had an opportunity to review those policies. I understand this consent will expire one (1) year from the date this document is signed. I acknowledge that this consent will apply to all patient encounters within Live Life Now Health prior to the expiration of this consent.