Please read the statement below and then type your name to serve as a digital signature in the space

provided: LIFETIME INSURANCE AUTHORIZATION I Authorize and Request that payment of insurance benefits to be made directly to Anthony Mannino D.O. for Services rendered. I understand that I am financially responsible for all charges, whether or not they are covered by my insurance. In the event of default, I agree to pay all costs of collection and reasonable attorney's fees. I hereby authorize this healthcare provider to release all information necessary to secure payment of benefits. I further agree that a photocopy of this agreement is as valid as the original. PATIENT REQUEST FOR CONFIDENTAL COMMUNICATION I authorize TLC FAMILY MEDICINE, P.C. to use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operation (TPO). TLC FAMILY MEDICIN P.C. Notice of privacy Practices a more complete description of such uses and disclosures.) MEDICAL RECORDS SHALL INCLUDE ALL CONFIDENTIAL, COMMUNICABLE DISEASES RELATED INFORMATION, CONFIDENTAL ALCOHOL OR SUBSTANCE ABUSE RELATED INFORMATION, AND MENTAL HEALTH DIAGNOSIS/TREATMENT. Also items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others. Release of Medical Information to other family Members Release of Medical Information to friend And/or Devices, such as FAX, Voice Mail, Answering Machines I Authorize the Release of Information to: _______________________________________Relationship:________________________ Please release Medical Information to: FAX machine Number:___________________________________ Voice Mail Number: ___________________________________ Answering Machine at this number: ___________________________________ Mail Medical Information to: ___________________________________ Patients Name: ___________________________________ Patients Signature: ___________________________________ If Minor, parent or guardian Signature: ___________________________________ YES YES YES NO NO NO

TLC FAMILY MEDICINE: Dr. Anthony Mannino D.O. Due to the high number of canceled and missed appointments, we are sorry to announce that we do charge a $25.00 for those appointments that are not canceled within a 24 hour notice. Physicals, Well Woman exams and Well Child visits will be charged $50.00. We apologize if this creates an inconvenience, but in order to serve you better this action is necessary. We do understand emergencies do arise, but we would appreciate it if you would call our office as soon as possible if you need to cancel or reschedule an appointment. Our office does not process retroactive referrals. It is your responsibility to notify our office 7-14 days in advance if an appointment with a specialist is scheduled. We are also unable to process same-day referrals, if you do not have a referral before you arrive at the specialists office you will have to reschedule your appointment for another day when you do have a referral. Your insurance company is contracted with specific outpatient facilities for lab and diagnostic test and Specialists. We try to refer you to specialists that Dr. Mannino recommends; however we are limited to those specialists contracted with your insurance. Dr. Mannino makes every effort to order medications that are on your insurance formulary. Therefore, we need to know as soon as possible if your insurance changes. Please phone the office when your insurance changes and drop off or fax us the front and back of your new card. Otherwise notify our office on your next visit so we can update your chart. If your insurance is terminated and you were seen in this office, you will be responsible for payment in full will be billed for the visit (visits). When Dr. Mannino orders Labs, X-rays, and diagnostic tests we make every effort possible to send you to a contracted facility, but you are responsible for the payment of these tests, and therefore it is your responsibility to know who is contracted with your insurance, and where you are to go for labs, x-rays and diagnostic tests. Please refer to your insurance manual or call your member services for locations contracted with your insurance to verify that they are contracted before any tests are completed. Signature of Patient:____________________________________ If Minor, Parent Signature:_______________________________ Date:__________________________