I authorize Justin Malhotra, MD and its contracted providers to provide me with their services by using telemedicine. I understand that telemedicine is the use of electronic information and communication technologies by a healthcare provider used to deliver services to an individual when they are located at a different location or site than I am. MBH and its contracted providers will not perform an in-person examination during the telemedicine visit. They will rely solely on the information telecommunicated. I understand that there are risks involved with telemedicine, including but not limited to: loss of records from failure of electronic equipment; power failure with loss of communication; connections issues, etc. Additionally, signs and symptoms that might be detected during an in-person examination may not be detected through telemedicine. I understand that the laws that protect privacy and the confidentiality of medical information, including HIPPA, also apply to telemedicine. I understand that I will be responsible for any copayments or coinsurances that apply to my telemedicine visit. I understand that I have the right to withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I have read and understood the information provided above and I consent to receiving telemedicine services.

Authorization to Disclose Protected Health Information (This form is for all record requests).

By signing this Authorization, I authorize my Health Care Provider to disclose my protected health information.

1. Information authorized for disclosure, if included in my records: Complete Health Record, Visit/Discharge Summary, Clinical Documentation of Physical, Documentation of Consultation, Immunization Records, Progress Reports, Radiology and Diagnostic Imaging Reports, Photographs, Videos, Digital or Other Images, Pathology Reports, Laboratory tests (please specify), Other (please specify)

2. If applicable, I also give permission for the following "Sensitive Protected Health Information" to be disclosed: Acquired Immunodeficiency Syndrome (AIDS) or Infection with Human Immunodeficiency Virus(HIV), Behavioral Health Services / Psychiatric Care, Treatment for Alcohol and/or Drug Abuse, Sexually Transmitted Diseases (STD), Genetic Counseling / Testing

I understand that the information disclosed pursuant to this Authorization, except information protected by Federal and/or State regulations about confidentiality of drug and alcohol abuse records, HIV and Mental Health, may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations or other applicable state and federal laws. The purpose for which disclosure is authorized:, Medical Care, Insurance Benefit, Eligibility, Immunization. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the provider(s) of care. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to review or contest a claim. If this authorization pertains to oneself as the patient, the expiration date can be documented as unlimited. If documented as such it is the responsibility of the individual to notify the practice of any life changes, i.e. guardianship, so that appropriate documentation is given for the change. I understand that any disclosure of healthcare information carries with it the potential for unauthorized and future re-disclosures as allowed by HIPAA and other federal privacy rules. If I have questions about disclosures of my health information, I can contact my provider of care. This facility, its employees, officers, and physicians are hereby released from from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. I authorize the custodian of records of: or other person/entity (specifically describe) to disclose/release the following information* (check all applicable): All records, Laboratory/pathology records, X-ray/radiology records, Billing records Abstract/Summary Pharmacy/prescription records, Other (describe specifically *Note: If these records contain any information from previous providers or information about HIV/AIDS status, cancer diagnosis, drug/alcohol abuse, or sexually transmitted disease, you are hereby authorizing disclosure of this information. I understand that after the custodian of records discloses my health information, it may no longer be protected by federal privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment; receive payment; or eligibility for benefits unless allowed by law. By signing below I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information.

CONFIDENTIAL HUMAN IMMUNODEFICIENCY VIRUS (HIV) TEST

HIV testing is a process that uses FDA-approved tests to detect the presence of HIV, the virus that causes AIDS and to see how HIV is affecting your body. The most common type of HIV test detects antibodies produced by the body after HIV infection. Test results are highly reliable but a negative test does not guarantee that you are healthy. Generally, it can take up to three months for HIV antibodies to develop. This is called the "window period". During this time, you can test negative for HIV even though the virus is in your body and you can give it to others. A positive antibody HIV test means that you are infected with HIV and can also give it to others even when you feel healthy. Other tests can detect the presence of virus in your blood, measure the amount of virus in your blood, measure the number of T- cells in your blood, or see if the virus is susceptible to HIV/AIDS medications. Some of these tests may require a second specimen to be obtained for further testing. Generally, test results will be available in about 2 weeks. If you consent by filling out and signing this form a specimen will be taken and you will be tested. If a rapid HIV test is used, results will be available the same day. If the rapid test detects HIV antibodies, it is very likely that you are infected with the virus, but this result will need to be confirmed. You will be asked to submit a second specimen for further testing. The results from this confirmatory test will be available to you in about 2 weeks. If you test positive, the local health department will contact you to help with counseling, treatment, case management and other services if you need them and want them. You will be asked about sex and/or needle-sharing partners, and voluntary partner counseling and referral services (PCRS) will be offered to you. The HIV test result will become part of your confidential medical record. If you are pregnant, or become pregnant, the test results will become part of your baby's medical record. Finding HIV infection early can be important to your treatment, which along with proper precautions, helps prevent spread of the disease. If you are pregnant, there is treatment available to help prevent your baby from getting HIV. If you have any questions, please ask your counselor, physician.

MEDICAL SERVICE CONSENTS (see descriptions below)

• Remote Patient Monitoring

• Remote Patient Monitoring

• Annual Wellness Visits

• Behavioral Health Integration

• Cardiovascular Screenings

• Obesity Counseling

• Cognitive Care Assessments

• Wound Care

• Smoking Cessation Counseling

• Alcohol Use Counseling

• Infection/Toxicology/Cancer Genetic Testing

Remote Patient Monitoring

RPM services allow your healthcare provider to monitor your health in between visits but this does not mean your provider will be monitoring you 24/7. RPM may help your healthcare provider identify issues that need to be addressed sooner than they would without RPM and allows you to communicate information to your provider without having to travel to the Providers office. RPM devices may rely on a good blue-tooth and/or internet connection to transmit data and deficiencies in connection may result in missed readings or failure to transmit information. I agree to allow Dr. Malhotra to provide Remote Patient Monitoring (RPM) services. These services include using remote health monitoring technology to wirelessly transfer health data, including, but not limited to blood pressure, weight, blood glucose, etc. RPM also includes consultation and guidance from my healthcare provider, who till have access to view this data and who may communicate with me or members of my care team, including family caregivers or guardians. I understand that:

• I am the only person who should be using the remote monitoring equipment as instructed.

• I will not use the device for reasons other than this Remote Patient Monitoring program.

• I can only participate in this program with one Medical Provider at a time.

• I will take my readings daily or as instructed by my Healthcare Provider as party of my participation in this program.

• My data will be electronically transmitted from the device to my provider in a safe and secure manner but that information security can never be 100% guaranteed.

• My provider will securely and confidentially store my collected data into my electronic medical record to the best of their ability, but information security can never be 100% guaranteed.

I acknowledge that:

• It is NOT AN EMERGENCY RESPONSE UNIT AND IS NOT MONITORED 24/7. Call 911 for immediate medical emergencies.

• By providing my phone and email information below, I agree to opt into automated and personalized text messages and phone calls. I understand that I can opt out of the automated reminders to take readings at any time.

Financial consent:

• My insurance will be charged monthly for this service. Co-payments may apply.

• My Healthcare provider owns the equipment and I am responsible for returning the equipment when my participation in the RPM program has ended.

• I will not tamper with the equipment and understand that I may be responsible for any fees associated with misuse or loss of the equipment. I can withdraw my consent to participate in this program at any time by contacting my physician and returning the equipment provided to me. I have read and understood the information and consent to participate in the Remote Patient Monitoring program, as stated above. I am aware that this consent is valid until I withdraw it.

Chronic Care Management

As a patient of Dr. Justin Malhotra with two or more chronic medical conditions, you may benefit from a new program that is now being offered to all (Medicare Ca) patients. Our goal is to make sure you get the best care possible from everyone involved with your health care. We can help coordinate your visits with other doctors, laboratory and diagnostic facilities, and other health care providers; we can talk to you on the phone about how you are feeling; we can help you with the management of your medications; and we will provide you with a comprehensive care plan and assess your health goals. Medicare will allow us to bill for these services during any month that we have provided at least 20 minutes of non-face-to-face care of you and your conditions, hence you may be billed for a portion of CCM services. You must provide us with your consent to participate once a year.

The assigned clinician in charge of your care is - Justinder Malhotra, MD.

Please know other staff from our practice will talk to you or handle issues related to your care, but please know that Justinder Malhotra, MD will supervise all care provided by our staff or clinicians involved in your care. By signing this agreement, you agree and consent to the following:

• You consent to Justinder Malhotra, MD and staff providing CCM services to you.

• As needed, as part of your coordination of care we will share your health information electronically with other treating providers involved in your care. Please rest assured that we continue to comply with all laws related to the privacy and security of your health information.

• These chronic care management services are subject to the usual Medicare deductible and coinsurance applied to physician services. Patients with a supplemental policy generally do not have to pay for out of pocket copays. Patients without a supplemental policy may be responsible for copays up to $8.71 per month. Should you ever have questions about what we did each month to manage your care; our office will provide a record of our time spent.

• We will bill Medicare and/or your insurance carrier for CCM services once a month. Although you may or may not come to our office every month, your account will reflect these charges, and you may be responsible for a portion of CCM services. Our office will have a record of time spent managing your care should you ever have a question about what we did each month.

• Only one physician`s office can provide CCM services to you during a calendar month. Therefore, if another one of your physicians has offered to provide you with this service, you will need to choose which physician is best able to treat you and all of your conditions. Please let us know if you have entered into a similar agreement with another physician`s/practice.

You have the following rights with respect to CCM services:

• A written or electronic copy of your comprehensive Care Plan from our practice to help you understand how to care for your conditions so that you can be as healthy as possible.

• You have the right to Stop CCM services at any time for any reason. Because your signature is required to discontinue your chronic care management services, please ask any of our staff members for the CCM termination form.

• If you wants to terminate CCM services then you need to call the office and speak to CCM Manager/Office Manager

Annual Wellness Visits

These are annual wellness questions that monitor the status of preventative health & screenings covered by Medicare (such as colonoscopy, mammogram, immunizations)

Behavioral Health Integration

These are monthly behavioral questions used to monitor status of conditions such as depression, anxiety or other mental health illnesses.

Cardiovascular Screenings

These are annual questions to assess risk of Cardiovascular disease for those at risk for such as but not limited to Hypertension, Diabetes Mellitus, Obesity, Peripheral Vascular disease.

Obesity Counseling

These are questions, weight checks and lifestyle counseling on a routine schedule of weekly/biweekly/monthly up to 6 months to help aid in weight loss.

Cognitive Care Assessments

These are quarterly questions and tests to monitor the status of cognitive conditions such as but not limited to Dementia.

Wound Care Management

This is a service completed at home or in the office for those who have chronic wounds such as but not limited to Pressure Ulcers, Diabetic wounds, Venous Ulcers.

Smoking Cessation Counseling

These are questions for those at risk for Nicotine dependence up to 7 times per year to help reduce smoking use.

Alcohol Use Counselling

These are questions for those at risk for Alcohol dependence up to 4 times per year to help reduce alcohol use.

Infection/Toxicology/Cancer Genetic Testing

This is a service completed at home or in the office in collaboration with Lab Collector to expedite diagnosis/treatment of various infections (ie UTI, COLITIS, URI) preventing delayed treatment; routine monitoring of toxicology for controlled substances and other potent medications; one time cancer screenings for those at risk.

I agree to participate in the above mentioned programs at this time and/or previously verbally agreed at an earlier start date as discussed with Dr. Justin Malhotra at the time he first started treating my chronic medical conditions. Our goal is to provide you with the best care possible, to keep you out of the hospital, to minimize costs and any inconvenience to you due to unnecessary visits to doctors, emergency rooms, labs, or hospitals. We know your time and your health is valuable. We hope that you will consider participating in our practice’s multiple programs. Thank you.