Authorization/Consent for Care/Service: I understand and have been informed of the Assisted Health Care options available and of the selection of providers from which I may choose; and I do hereby authorize Unify Health Medical Supply to provide assisted medical equipment, supplies, and services as needed or otherwise prescribed by—and under the direction of—the corresponding physician (herein referred to as “Assisted Health Care”).

Assignment of Benefits/Authorization for Payment: I do hereby assign any and all right, title, and interest in and to any and all payments made from the corresponding insurer(s), Medicare/Medicaid, and/or other responsible third parties (herein “Payment Source”), for any and all Assisted Health Care furnished by Unify Health Medical Supply. In addition, I do hereby authorize Unify Health Medical Supply to seek such payments on my behalf and request that all such payments be made directly to them. I also understand that, as a courtesy, Unify Health Medical Supply may directly bill the corresponding Payment Source. I also understand and acknowledge that any changes in my coverage or policy must be reported to Unify Health Medical Supply within thirty (30) days of such changes.

Release of Information: I hereby request and authorize Unify Health Medical Supply—along with the prescribing physician, hospital, and any other holder of information in any form that’s relevant to Assisted Health Care—to release such information upon written request by any Payment Source, relevant physician, or any other related medical personnel or agency involved with Assisted Health Care. I also hereby authorize Unify Health Medical Supply to review the relevant medical history and any other necessary information for the purpose of providing the Assisted Health Care.

Returned Goods: I understand and agree that, due to Federal and State Regulations, ancillary items prescribed for Assisted Health Care cannot be re-dispensed; and therefore, ancillary items cannot be returned for credit. Likewise, I understand and agree that all “sale” items cannot be returned; however, any home medical equipment or supplies that are rented will be returned after the Assisted Health Care has ended. I also understand that if any of the medical equipment or supplies proved as part of the Assisted Health Care are defective or otherwise non- functional, Unify Health Medical Supply must be notified within twenty-four (24) hours of the set-up; whereupon the defective or non- functioning item will be repaired or exchanged.

Complaint Reporting: I hereby acknowledge that I have been informed of, and understand, the procedure for reporting a grievance should I become dissatisfied with any portion of Assisted Health Care, and that, at any time, I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of the Assisted Health Care. I am also informed the number (888)-720-7070 to speak with the customer service.

By Signing this Patient Service Agreement, I do hereby declare and attest under penalty of law that, to the best of my knowledge, all of the above declarations and statements are true, and I further understand and agree—that for valuable consideration, the sufficiency of which is hereby acknowledged—to be bound by the terms and conditions herein.