FINANCIAL RESPONSIBILITY AND BILLING CONSENT AGREEMENT

I understand and agree that: • I — or the person signing or guaranteeing payment (Guarantor), including a parent or authorized guardian — am responsible for any charges not covered by insurance, for any reason. Such charges are due when the patient's treatment stops or the patient is discharged. • I may request an estimate of charges based on the Cloud Health Medical pricelist ("chargemaster") in effect at the time of service. This estimate may need to be prepared and mailed. It will be an estimate only; actual costs may vary. • Cloud Health Medical may bill the patient's insurance on our behalf, but may also ask for payment in full in advance, unless Cloud Health Medical agrees otherwise with the insurance company or other payer. • I may be billed by Cloud Health Medical. • I am responsible for all charges, and this agreement covers all Cloud Health Medical accounts, including those for doctors, nurse practitioners, and physician assistants.

Should the bill be sent for collection, I will pay any resulting costs, including attorney's fees, court costs, and collection agency fees. Cloud Health Medical and its providers, affiliates, agents, and contractors, including debt collectors, may call or text the cell or home phone number I provide, using any type of artificial or pre-recorded voice or auto-dialer technology, for any purpose including billing and collections. Cloud Health Medical may access the patient's (and/or guarantor's) consumer credit report to help collect amounts owed or to determine eligibility for financial aid or charity care.

I understand that the patient's insurance or payer may not cover all costs. I agree that the patient (and I, as guarantor) am personally responsible for any costs not covered by insurance or payer, or that exceed benefit limits, including but not limited to: • Self-administered medications (medicines the patient would normally take on their own) • Certain durable medical equipment • Certain medical supplies • Services and supplies that the insurance or payer determines are experimental, investigational, not covered for any other reason, or not medically necessary but that the patient wishes to receive.

If the patient is a beneficiary of a government health program, I agree that neither the patient, the patient's healthcare provider, the affiliated physician practices, nor any of the healthcare organization(s) or provider(s) with whom Cloud Health Medical partners to provide healthcare and pharmacy services will submit a claim for reimbursement to any federal or state healthcare program except Medicare Advantage plans for the costs of the services and products provided through the Services. Submission of claims to Medicare Advantage plans is expressly permitted. All other government program claims (e.g., Medicare Part B (FFS), Medicaid, Tricare, Veterans Affairs) are strictly prohibited.

Failing to attend an appointment or canceling an appointment within 24 hours of the scheduled time will result in a cancellation fee of $50.

By submitting this form online, I acknowledge and agree that: My electronic signature constitutes my legal signature and is binding to the same extent as a handwritten signature under applicable law, including the Electronic Signatures in Global and National Commerce Act (E-SIGN) and applicable state electronic signature laws. I authorize Plus Wellbeing to bill my insurance (if applicable) and I agree to be responsible for applicable copays, coinsurance, deductibles, non-covered services, and any disclosed fees. I have had the opportunity to read this Agreement in full prior to signing. If I am signing as a parent or authorized guardian, I confirm my authority to do so and agree to provide documentation of such authority upon request.