AFFIRMATION AGREEMENT AND AUTHORIZATION

Liza Maniquis-Smigel, MD LLC

Physical Medicine & Rehabilitation

Spine, Sports & Electrodiagnostic Medicine

Prolotherapy

1. The foregoing questions are true and correct to the best of my knowledge. Yes 2. I aknowledge and understand that I am responsible for all of the services rendered to me or my dependent family member by Liza Maniquis-Smigel, M.D., LLC. I agree to pay promptly upon receipt of the monthly statement. Yes 3. I hereby authorize payment of medical benefits on my behalf to be made directly to Liza Maniquis-Smigel, M. D., LLC. for services rendered. Yes 4. I voluntarily consent to have Liza Maniquis-Smigel, MD provide medicare care, including diagnostic and treatment procedure deemed necessary to aid and assist in the diagnosis and treatment of my dependent family member. Yes I understand and agree E-Signature* Date of E-Signature*

AGREEMENT TO RELEASE CONFIDENTIAL INFORMATION

I understand and agree that Liza Maniquis-Smigel, M.D., will keep any and all information regarding my medical condition confidential withinthe laws of the HIPAA Privacy Act. Written consent must be obtained from me for discoloser of my medical information to any person or entity other thanmy referring physician, another medical facility to which I may be referred by Liza Maniquis-Smigel, M.D., LLC, or the party(ies) obligated to pay for said services. Yes I understand and agree E-Signature* Date Of E-Signature*

MEDICARE AUTHORIZATION (Medicare patients only)

I request that payment under the MEDICARE insurance program be made directly to Liza Maniquis-Smigel, M.D., LLC for any medical services provided dureing the effective period of this authorization Liza Maniquis-Smigel, M.D., LLC to release to the Social Security Administration or its intermediaries or carriers any information necessary for this claim or any related Medicare claim. I authorize the use of a copy of this signed agreement to be used in place of its original. Yes I understand and agree E-Signature Date E-Signature

PRESCRIPTION POLICY (Please type in your initial below)

Regular follow up visits with Dr. Smigel are necessary for continuation of prescription medications. In some cases, refills may be approved by Dr. Smigel between follow up visits. Please plan ahead, as any approved refills require at least 24 hour (one working day) notice to process for both written or call-in prescriptions.* untitled element

NOTICE OF PRIVACY PRACTICE (NPP)

I have received the Notice of Privacy practice and acknowledge the opportunity to review the NPP as provided by HIPAA regulations* If patient is unable to provide written acknowledgement, please check reason: Communication Barrier Refusal Other

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