Medical Information Release Form (HIPAA Release Form)

RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS

I hereby authorize my physician (or whomever he may designate) to administer medical treatment as is necessary for a patient in my condition. I hereby authorize Watermark Medical Partners to release any and all information acquired as the course of myexamination or treatment which may be requested by guarantors, insurers, managed careorsimilar network organizations or payers of my account. In addition, I authorize payment of medical benefits to Watermark Medical Partners.

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

I have been provided with a Notice of Privacy Practices that describes the uses and disclosures of certain health information. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right tochange their notice and practices _and prior to implementation will provide a copy or any revised notice.

DISCLOSURE-OF PROTECTED HEALTH INFORMATION TO ANOTHER PARTY

I alsoauthorize Watermark Medical Partners to useand/or disclose certain protected health information (PHI) about me to the party or parties listed below.

Release of Information:

I authorize the release of information including thediagnosis, records; examination rendered to me and claims information. This information may be released to:           ·

This Release of Information will remain in effect until terminated by me in writing.

Please complete the Watermark Patient Lien Form Below.

RE: Authorization Agreement to Pay Physician Fee

I hereby authorize the above doctor and/or medical facility to furnish you, my attorney, with a full report of my final examination, diagnosis, medical treatment, and prognosis, etc., arising out of the above referenced accident.

I hereby authorize and direct you, my attorney, to pay directly to said doctor such sums that are due and owing for medical services, treatment and care, which have been rendered to me by reason of this accident and by reason of any other bills which are due to his office; and you, my attorney, are expressly directed to withhold such sums from any payments, settlements, dispositions, proceeds, verdicts, and/or any other sources received on my behalf and place them in your trust account for the purpose of adequately protecting and paying in full and promptly said medical services rendered to me by said doctor and/or his office.

I further direct you, my attorney, to pay to said doctor that amount which is due and owing to him for medical care, examination, treatments, and other services which he has extended on my behalf within thirty days of receipt of said funds. I do fully realize and understand that I remain personally responsible for said medical services and associated medical billings and that this obligation is not contingent upon my receiving any settlement. With this understand in mind, I agree to give said doctor information concerning all insurance policies that may cover said medical treatment and assign to him the benefits therein. I further agree to notify said doctor and pay his billings at such time as I may personally receive payments made directly to myself for these services from my own or any other medical insurance carrier.

It if further agreed and understood that should I, as the patient, choose to change attorneys, that this lien will be binding and in effect as if it had been signed by the new attorney. This medical lien may not be altered, modified, revoked, or compromised in any way without approval of the doctor and/or medical facility and shall always remain in force and effect until all monies due have been paid. Any controversy arising out of this agreement for medical services rendered to me shall be submitted and arbitrated pursuant to the rules and regulations of the American Arbitration Association.

The undersign attorney acknowledges that he/she is legal counsel of record for the above-named patient and that he/she agrees to observe all those terms of this medical lien. Said attorney agrees to notify doctor within thirty days if said patient substitutes the attorney and supply the name, address, and telephone number of the newly acquired attorney and specifically place said attorney on notice of pending lien. If failure to notify the doctor of such change of attorneys shall result in the doctor’s failure to receive recovery pursuant to this lien, it shall be considered a breech by the undersigned attorney of the terms of this lien agreement.

Thank you. To obtain a copy for your records, please send us a request at info@watermarkmp.com.

MOHSIN SHAH MD
PHYSICIAN-PATIENT ARBITRATION AGREEMENT

Article l : Agreement to Arbitrate: It is understood that any dispute as to medical malpractice. that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children. whether born or unborn. at the time of the occurrence giving rise to any claim. In the case of any pregnant mother. the term "patient" herein shall mean both the mother and the mother's expected child or children.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician. and the physician’s partners. associates, association, corporation, or partnership, and the employees, agents, and estates of any of them, must be arbitrated including, without limitation. claims for loss of consortium. wrongful death. emotional distress or punitive damages. Filing of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rota share of the expenses and fees of the neutral arbitrator. together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of an arbitrator under this contract. This immunity shall supplement not supplant. any other applicable statutory or common law.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.

The parties consent to the intention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

The parties agree that provisions of California law applicable to health care providers shall apply to disputes with this arbitration agreement, including. but not limited to. Code of Civil Procedure Section 340.5 .:ind 667.7 and Civil Code Sections 3333.l and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05. however, depositions may be taken without prior approval of the neutral arbitrator.

Article 4: General Provisions: All claims based upon the same incident. transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received the claim. if asserted in a civil action. would be barred by the applicable California statute of limitations. or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered at any time for any condition.

Article 6: Retroactive Effect: If the patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:

If any provision of this arbitration agreement is held invalid or unenforceable. the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.