Ruby Medical, PC

Consent to Treatment/Health Care Agreement

Effective date: September 9, 2025

Consent to Treatment

I voluntarily consent to receive medical and health care services provided by Ruby Medical, PC physicians, employees and such associates, assistants, and other health care providers as my physicians deem necessary. I understand that such services may include diagnostic procedures, examinations, and treatments. I understand photographs, videotapes, digital and/or other images may be made/recorded for treatment and payment purposes only.

I acknowledge that Ruby Medical, PC may use health information exchange systems to electronically transmit, receive and/or access my medical information which may include, but is not limited to, treatments, prescriptions, labs, medical and prescription history, and other health care information.

I understand that this Consent to Treatment/Health Care Agreement will be valid and remain in effect as long as I attend or receive services from Ruby Medical, PC, unless revoked by me in writing with such written notice provided to each clinic I attend or from which I receive services.

Release of Medical Information

I acknowledge that "protected health information" pertains to my diagnosis and/or treatment at Ruby Medical, PC, including, but not limited to, information concerning mental illness (except for psychotherapy notes), use of alcohol or drugs, or communicable diseases such as Human Immunodeficiency Virus ("HIV") and Acquired Immune Deficiency Syndrome ("AIDS"), laboratory test results, prescriptions, medical history, prescription history, treatment progress or any other such related information.

I acknowledge that the "Notice of Privacy Practices" provides information about how Ruby Medical, PC and its workforce may use and/or disclose protected health information about me for treatment, payment, health care operations, and as otherwise allowed by law. I understand Ruby Medical, PC cannot be responsible for use or re-disclosure of information by third parties.

Financial Responsibility and Assignment of Benefits

In consideration for receiving medical or health care services, I hereby assign to Ruby Medical, PC physicians and providers my right, title, and interest in all insurance, Medicare/Medicaid, or other third-party payer benefits for medical or health care services otherwise payable to me. I also authorize direct payments to be made by Medicare/Medicaid and/or my insurance company or other third-party payer, up to the total amount of my medical and health care charges, to Ruby Medical, PC physicians. I certify that the information I have provided in connection with any application for payment by third-party payers, including Medicare/Medicaid, is correct.

I agree to pay all charges for medical and health care services not covered by, or which exceed, the amount estimated to be paid or actually paid by Medicare/Medicaid, my insurance company, or other third-party payer, and agree to make payment as requested by Ruby Medical, PC.

Effective date: September 9, 2025