Pickaway County Telehealth Form Signature Page

I * hereby authorize my provider to perform all tests or procedures relative to my illness, injury or examination and necessary for my care and treatment. I also authorize Adena to take photos, video, or audio recording of me for diagnostic, teaching, identification, care conferencing, and quality improvement purposes. I understand all of the following: • This authorization enables the provider to obtain pre-admission or continued length of stay certifications. • No guarantee has been made about the outcome of the care to be rendered. • Providers furnishing services to me may be independent contractors. I give my consent to be interviewed by the consulting health care provider through virtual visits. Virtual visits include face-to-face video/telehealth visits, virtual check-ins, telephone calls, and e-visits. I give my consent to be interviewed by the consulting health care provider. I also understand other individuals may be present to operate the video equipment and that they will take reasonable steps to maintain confidentiality of the information obtained. I understand that a limited physical examination will take place during the teleconference and that I have the right to ask my healthcare provider to discontinue the conference at any time. I understand that some parts of the exam may be conducted by individuals at my location at the direction of the consulting health care provider. I authorize the release of any relevant medical information about me to the consulting health care provider, any staff the consulting health care provider supervises, third party payers and other healthcare providers who may need this information for continuing care purposes. I hereby release Adena Health System, IT personnel and any other person participating in my care from any and all liability which may arise from the taking and authorized used of such videotapes, digital recording films and photographs. I have read this document and understand the risk and benefits of the telemedicine consultation and have had my questions regarding the procedure explained and I hereby consent to proceed under the conditions described in this document.

(* Throughout this document "I" will refer to "I and/or my parents or guardians," and "me" "myself" or "my" will refer to the patient. "Adena" will refer to Adena Health System, its attending doctors, other doctors, or agents of Adena.) Paying the Bill: Responsibility for Payment: I accept that I am financially responsible for all services rendered on my behalf for which a charge may be associated. I accept personal responsibility for all co-payments, deductibles, and non-covered services, as dictated by my insurance coverage, plus any collection costs for amounts personally owed by me. I acknowledge that not all services provided by Adena are covered by my insurance plan for one or more reasons, including but not limited to exclusions from my insurance plan, my insurance plan’s designation of the Adena as an out-of-network provider, and/or my failure to provide my insurance card. Assignment of Benefits: I certify that the information given by me in applying for payment is correct. If applicable, I authorize any holder of medical or other information about me to release this information to the Center for Medicare and Medicaid Services (CMS) and its agents. I request that payment of authorized benefits be made directly to Adena, on my behalf. I hereby appoint Adena as my authorized representative to pursue any claims, penalties, and administrative or legal remedies on my behalf for collection against any responsible payer, employer-sponsored medical benefit plans, third party liability carrier or, any other responsible third party (“Responsible Party”) for any and all benefits due me for the payment of charges associated with my treatment. This assignment includes all rights to recover attorney’s fees and costs for any such action brought by Adena as my assignee. This assignment may only be revoked in writing. This assignment shall not be construed as an obligation of Adena to pursue any such right of recovery. I acknowledge and understand that I maintain my right of recovery against my Responsible Party and the foregoing assignment does not divest me of such right. I agree to take all actions necessary to assist Adena in collecting payment from any such Responsible Party should Adena elect to collect such payment, including allowing Adena to bring suit against the Responsible Party in my name. If I receive payment directly from any source for the medical charges associated with my treatment, I acknowledge that it is my duty and responsibility to immediately pay any such payments to Adena.

Acknowledgments: I acknowledge all of the following: • Interpretive or translation services, if needed, are available and will be provided for free. • Adena's Notice of Privacy Practices and Patient Rights has been provided to me and a copy is available upon my request. • Adena’s list of the charges for common medical and surgical procedures is available upon my request. Contacting Me: I authorize Adena and its agents to contact me as needed for the following purposes: • gathering or confirming my insurance information; • billing me or collecting payment regarding care provided to me; • obtaining pre-admission or continued length of stay certification; • assessing and improving Adena’s quality of care; • evaluating the performance or qualifications of physicians and health care workers; • conducting medical and nursing training and education programs; • conducting or arranging for medical review and audit services; • ensuring compliance with legal, regulatory, and accreditation requirements; and • facilitating public health activities. I authorize Adena to receive or release my contact information, whether written, verbal or electronic (such as websites, portals, or faxes) to such employees or third parties as are necessary for these purposes.

I authorize Adena and its agents and assignees to contact me in the following ways: • by telephone (landline or cell) at any number I provide; • by leaving voice messages for me that include information about me, including amounts owed by me; • by text messages (standard text messaging rates may apply) or emails using any phone number or email addresses I provide; and • by using pre-recorded/artificial voice messages and/or an automatic dialing device (an auto dialer). I understand that my refusal to provide the consent described in this paragraph will not affect, directly or indirectly, my right to receive healthcare services from Adena. My Personal Information: General: I authorize Adena to share, release, or exchange all medical information to: • my providers, including referring providers; • agencies needed to facilitate continuity of care; • my insurance company, or its authorized representative, or medical assistance agency; • any collection agency Adena uses to collect payment for the services rendered; • and any government authority when required to do so by law. HIV, AIDS, and ARC: I authorize Adena to share any information concerning diagnosis of Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or testing for Human Immunodeficiency Virus (HIV) in the usual course of my care and treatment. Mental Health: I authorize Adena to share any information concerning diagnosis or treatment of a mental health condition in the usual course of my care and treatment.

Substance Abuse: I authorize Adena to share any information concerning diagnosis or treatment for substance abuse and conditions related to substance abuse in the usual course of my care and treatment. Health Information Exchange (HIE) & Other Data Programs: Adena participates in a Health Information Exchange (HIE) and certain other data programs related to payor reimbursement (collectively, “Data Exchanges”). Adena uses Data Exchanges to securely provide access to my health records for a better picture of my health needs and to facilitate payment for health services. I authorize Adena to share my health information with the Data Exchanges. I acknowledge that this could include information regarding diagnosis or treatment for conditions such as HIV, AIDS, and ARC, substance abuse, or mental health conditions. I acknowledge that if I do not consent to the release or disclosure of information to the Data Exchanges described above I must provide advance written notice to the Adena Medical Records Department. Work Injuries: In the event of a work-related illness/injury, I authorize the release of all related medical information to the Adena Occupational Health Center and any other party with an interest in the claims defined by Ohio law.

This NOTICE OF PRIVACY PRACTICES (this“Notice”) applies to Adena Health System (“AHS”), operating as an organized health care arrangement that includes Adena Regional Medical Center (“ARMC”), Greenfield Area Medical Center (“GAMC”), Pike Health Services, Inc., doing business as Pike Community Hospital (“PCH”), ARMC off-campus outpatient hospital departments (Western Avenue, Jackson, Waverly, Circleville, Washington Court House), Adena Medical Group (“AMG”) Physicians, Adena Home Health, LLC (“AHH”), Adena Hospice, LLC (“AH”), Adena Home Infusion, DME, and Respiratory, LLC (“AHI”), Oak Hill, Hillsboro, Wellston, Adena Care, Inc., Adena Healthcare Collaborative, LLC. and other licensed health care professionals seeing and treating patients (“Patients”) within any of these facilities. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR PLEDGE TO YOU. Your health information -- which means any written or oral information that we create or receive that describes your health condition, treatment or payments -- is personal. Therefore, Adena pledges to protect your health information as required by law. We give you this Privacy Notice to tell you (1) how we will use and disclose your “protected”health information, or “PHI”and (2) how you can exercise certain individual rights related to your PHI as a Patient of Adena. Please note that if any of your PHI qualifies as mental health records, alcohol and drug treatment records, communicable disease records or genetic test records, we will safeguard these records as“Special PHI”which will be disclosed only with your prior express written authorization, pursuant to a valid court order or as otherwise required by law. We are required by law to maintain the privacy of your PHI and to provide you with this notice of our legal duties and privacy practices.

I. HOW WE WILL USE AND DISCLOSE YOUR PHI A. To Provide Treatment. We may use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the management or coordination of your health status and care with another health care facility, whether part of Adena or outside of Adena. For example, we may disclose your PHI to a pharmacy to fill a prescription or to a laboratory to order a blood test. We may also disclose your PHI to another physician who may be treating you or consulting with us regarding your care. B. To Obtain Payment. We may also use and disclose your PHI, as needed, to obtain payment for services that we provide to you. This may include certain communications to your health insurer or health plan to confirm (1) your eligibility for health benefits, (2) the medical necessity of a particular service or procedure, or (3) any prior authorization or utilization review requirements. We may also disclose your PHI to another facility involved in your care for the other facility’s payment activities. For example, this may include disclosure of demographic information to another physician practice that is involved in your care, or to a hospital where you were recently hospitalized, for payment purposes. C. To Perform Health Care Operations. We may also use or disclose your PHI, as necessary, to carry on our day-to-day health care operations, and to provide quality care to all of our Patients, but only on a “need to know” basis. These health care operations may include such activities as: quality improvement; physician and employee reviews; health professional training programs, including those in which students, trainees, or practitioners in health care learn under supervision; accreditation; certification; licensing or credentialing activities; compliance reviews and audits; defending a legal or administrative claim; business management development; and other administrative activities. In certain situations, we may also disclose you PHI to another health care facility or health plan to conduct their own particular health care operation requirements. D. To Contact You. To support our treatment, payment and health care operations, we may also contact you at home, either by telephone, mail, or electronic delivery from time to time (1) to remind you of an upcoming appointment date or (2) to ask you to return a call to Adena unless you ask us, in writing, to use alternative means to communicate with you regarding these matters. We may also contact you by telephone to inform you of specific test results or treatment plans, but only with your prior written authorization. E. To Be In Contact With Your Family or Friends. Additionally, we may also disclose certain PHI to your family member or other relative, a close personal friend, or any other person specified by you from time to time, but only if the PHI is directly related (1) to the person’s involvement in your treatment or related payments, or (2) to notify the person of your physical location or a sudden change in your condition, while receiving treatment at our office. Although you have a right to request reasonable restrictions on these disclosures, we will only be able to grant those restrictions that are reasonable and not too difficult to administer, none of which would apply in the case of an emergency. F. Clergy Directory. The same information that is in the facility directory plus your religious affiliation will be provide to members of the clergy unless you choose to be excluded during the registration process.

G. To Conduct Research. Under certain circumstances, we may use and disclose explicitly permitted PHI for research purposes, but only if the research is subject to special approval procedures and the necessary rules governing uses and disclosures are agreed to by the researchers. For example, a research project may compare two different medications used to treat a particular condition in two different groups of patients by comparing the patients’ health and recovery in one group with the second group. Any other research will require your written authorization. H. According to Laws That Require or Permit Disclosure. We may disclose your PHI when we are required or permitted to do so by any federal, state or local law, as follows: 1. When There Are Risks to Public Health. We may disclose your PHI to (1) report disease, injury or disability; (2) report vital events such as births and deaths; (3) conduct public health activities; (4) collect and track FDA-related events and defects; (5) notify appropriate persons regarding communicable disease concerns; or (6) inform employers about particular workforce issues. 2. To Report Suspected Abuse, Neglect Or Domestic Violence. We may notify government authorities if we believe that a Patient is the victim of abuse, neglect or domestic violence, but only when specifically required or authorized by law or when the patient agrees to the disclosure. 3. To Conduct Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities including audits; civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight, but we will not disclose your PHI if you are the subject of an investigation and your PHI is not directly related to your receipt of health care or public benefits.

4. In Connection With Judicial and Administrative Proceedings. We may disclose your PHI in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal. In certain circumstances, we may disclose your PHI in response to a subpoena if we receive satisfactory assurances that you have been notified of the request or that an effort was made to secure a protective order. 5. For Law Enforcement Purposes. We may disclose your PHI to a law enforcement official to, among other things, (1) report certain types of wounds or physical injuries, (2) identify or locate certain individuals, (3) report limited information if you are the victim of a crime or if your health care was the result of criminal activity, but only to the extent required or permitted by law. 6. To Coroners, Funeral Directors, and for Organ Donation. We may disclose PHI to a coroner or medical examiner for identification purposes, to determine cause of death or for the coroner or medical examiner to perform other duties. We may also disclose PHI to a funeral director in order to permit the funeral director to carry out their duties. PHI may also be disclosed for organ, eye or tissue donation purposes. 7. In the Event of a Serious Threat to Health or Safety, or For Specific Government Functions. We may, consistent with applicable law and ethical standards of conduct, use or disclose your PHI if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public, or for certain other specified government functions permitted by law. 8. For Worker’s Compensation. We may disclose your PHI to comply with Worker’s Compensation laws or similar programs. 9. To Conduct Fundraising. Under certain circumstances, we may use and disclose explicitly permitted PHI to communicate with you and conduct fundraising activities on our behalf, but only when permitted by HIPAA. Please note that you always have the right to “opt out” of receiving any future fundraising communications and any such decision will have no impact on your treatment or payment for services. 10. To Communicate With You Regarding Your Treatment. We may also communicate information to you, from time to time, that may encourage you to use or purchase a particular product or service, but only as it relates to your treatment and only when permitted by HIPAA.

I. With Your Prior Express Written Authorization. Other than as stated above, we will not disclose your PHI, or more importantly, your Special PHI, without first obtaining your express written authorization. We will not use or disclose your PHI in any of the following situations without your written authorization: 1. Uses and disclosures of Special PHI (if recorded by us in the medical record) except to carry out your treatment, payment or health care operations, to the extent permitted or required by law; 2. Uses and disclosures of PHI to conduct certain marketing activities that may encourage you to use or purchase a particular product or service for which HIPAA requires your prior express written authorization; 3. Disclosures of PHI that constitutes a sale of your PHI under HIPAA; 4. Uses and disclosures of certain PHI for fundraising purposes that are not otherwise permitted by HIPAA; 5. Psychotherapy notes; and 6. Other uses and disclosures not described in this Notice.

II. YOUR INDIVIDUAL RIGHTS CONCERNING YOUR PHI A. The Right to Request Restrictions on How We Use and Disclose Your PHI. You may ask us not to use or disclose certain parts of your PHI but only if the request is reasonable. For example, if you pay for a particular service in full, out-of-pocket, on the date of service, you may ask us not to disclose any related PHI to your health plan. You may also ask us not to disclose your PHI to certain family members or friends who may be involved in your care or for other notification purposes described in this Privacy Notice, or how you would like us to communicate with you regarding upcoming appointments, treatment alternatives and the like by contacting you at a telephone number or address other than at home. Please note that we are only required to agree to those restrictions that are reasonable and which are not too difficult for us to administer. We will notify you if we deny any part of your request, but if we are able to agree to a particular restriction, we will communicate and comply with your request, except in the case of an emergency. Under certain circumstances, we may choose to terminate our agreement to a restriction if it becomes too burdensome to carry out. Finally, please note that it is your obligation to notify us if you wish to change or update these restrictions after your visit by contacting the Patient Advocate directly. B. The Right to Opt Out of Fundraising. We may use or disclose your name, address, telephone number or e-mail information, age, date of birth, gender, health insurance status, dates of service, department of service information, treating physician information or outcome information, to a business associate or institutionally related foundation, for the purpose of raising money for AHS’ benefit. Although AHS may contact you to raise funds for AHS, you have the right to opt out of receiving future fundraising communications, and your decision will have no impact on your treatment or payment for services at AHS. C. The Right to Receive Confidential Communications of PHI. You may request to receive communications of PHI from us by alternative means or at alternative locations, and we will work with you to reasonably accommodate your request. For example, if you prefer to receive communications of PHI from us only at a certain address, phone number or other method, you may request such a method.

D. The Right to Inspect and Copy Your PHI. You may inspect and obtain a copy of your PHI that we have created or received as we provide your treatment or obtain payment for your treatment. A copy may be made available to you either in paper or electronic format if we use an electronic health format. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and PHI that is subject to a law prohibiting access. Depending on the circumstances, you may have the right to request a second review if our Director of Health Information Management (HIM) denies your request to access your PHI. Please note that you may not inspect or copy your PHI if your physician believes that the access requested is likely to endanger your life or safety or that of another person, or if it is likely to cause substantial harm to another person referenced within the information. As before, you have the right to request a second review of this decision. To inspect and copy your PHI, you must submit a written request to the Director of Health Information Management (HIM). We may charge you a fee for the reasonable costs that we incur in processing your request. E. The Right to Request Amendments To Your PHI. You may request that your PHI be amended so long as it is a part of our official Patient Record. All such requests must be directed to the Director of Health Information Management (HIM). In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may respond to your statement in writing and provide you with a copy. F. The Right to Receive an Accounting of Disclosures of PHI. You have the right to request an accounting of those disclosures of your PHI that we have made for reasons other than those for treatment, payment and health care operations, which are specified in Section II (A-C) above. The accounting is not required to report PHI disclosures (1) to those family, friends and other persons involved in your treatment or payment, (2) that you otherwise requested in writing, (3) that you agreed to by signing an authorization form, or (4) that we are otherwise required or permitted to make by law. As before, your request must be made in writing to the Director of Health Information Management. The request should specify the time period, but please note that we are not required to provide an accounting for disclosures that took place prior to April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. G. The Right to Receive Notice of a Breach. You have the right to receive written notice in the event we learn of any unauthorized acquisition, use or disclosure of your PHI that was not otherwise properly secured as required by HIPAA. We will notify you of the breach as soon as possible but no later than sixty (60) days after the breach has been discovered.

H. The Right to File A Complaint. You have the right to contact our Patient Advocate at any time if you have questions, comments or complaints about our privacy practices or if you believe we have violated your privacy rights. You also have the right to contact our Privacy Officer or the Department of Health and Human Services’ Office for Civil Rights in Baltimore, Maryland regarding these privacy matters, particularly if you do not believe that we have been responsive to your concerns, you may also contact the Ohio Department of Health, PCSU, at 1-800-342-0553. We urge you to contact our Patient Advocate if you have any questions, comments or complaints, either in writing or by telephone as follows: Adena Health System Patient Advocate 272 Hospital Road Chillicothe, Ohio 45601 Complaint Line: 1-877-779-7364 Please note that we will not take any action, or otherwise retaliate, against you in any way as a result of your communications to AHS or to the Department of Health and Human Services’ Office for Civil Rights. As always, please feel free contact us. We look forward to serving you as a Patient. A. Your Right to Revoke Authorization. Any other uses and disclosures not described in this Notice will be made only with your written authorization. Please note that you may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization. KD_5079530_1.DOC