NervePro Medical Corp is committed to providing you the best medical care. To help achieve this goal, you must have a clear understanding of our financial policies to prevent any misunderstanding.

FINANCIAL POLICY

I hereby authorize my insurance company/companies to make payment(s) directly to:

NervePro Medical Corporation and/or Bruce Cleeremans, MD

NervePros facility, providers, and staff may utilize my insurance benefits to collect for all services rendered to me by the aforementioned. I further accept liability for any medical devices, products, or services prescribed and/or dispensed to me by the above physician should they not be reimbursable by my insurance company. If I am uninsured or decide to receive treatment outside of my insurance network, I agree to pay a predetermined cash price set by the office for all services rendered to me. I understand and agree to pay all charges in full at the time of service. I acknowledge that Nervepro Medical Corporation reserves the right to revise, update, amend, or change their financial policy and cash prices for services at any time.

IT IS YOUR RESPONSIBILITY TO KNOW THE DETAILS OF YOUR HEALTH PLAN

If you are in doubt as to whether a provider, medication, procedure, lab test, diagnostic study, or imaging

service is covered, or you are unsure of the facility at which it must be performed, please call your plans

member services department to verify. Our office is not responsible for any out-of-pocket costs incurred due to the use of out-of-network providers or facilities. We are also not responsible for unauthorized imaging, labs, tests, or other procedures not preauthorized by your insurance. We attempt to refer you to providers, labs, and facilities that are contracted with your health plan; However, we are listed as a provider on over 100 health plans, and it is not possible for our office to track the details of

each individual plan since each policy is written to provide coverage adapted to the needs of the subscriber. Additionally, insurance companies are constantly updating their coverage criteria and network limits internally without sending notification to providers.

CANCELLATION POLICY

Cancellation/No Show Fee: $65.00

Cancellation/No Shows are defined as in person appointments or telemedicine appointments that are no

showed, rescheduled, or cancelled with less than a 24-hour notice.

As a new patient at NervePro, you are automatically signed up for our automated call and text reminders

(covered under TPO). If the number you put on file is a landline, you will only receive call reminders. If the number on file is a mobile phone, you will receive both call and text reminders. You may also request to opt into email reminders in lieu of, or in addition to phone and/or text reminders. You may opt out of reminders at any time by submitting a written request to our office. Once you have opted out of our reminder system, you relieve us of our responsibility to confirm your appointment(s). You then assume all responsibility for monitoring your appointment(s). Please note, if you opt out of reminders, you will still be liable for all cancellation/no show fees you may incur. Outstanding balances, fees, or any other charges that fall delinquent and are not satisfied by the posted due dates will be sent to collections; There will be a 30% collection fee added to the outstanding balance of any account sent to collections.

Our automated reminder system will contact you multiple times prior to your appointment by phone and/or text. Our automated reminder system allows you to confirm, cancel, or request to reschedule your appointment. You will be prompted to press a predesignated number in order to confirm, cancel, or request to reschedule. Please follow the prompts provided in the reminder message.

You may contact our office directly to confirm, cancel, or reschedule; However, we recommend you use our automated system. If you request to reschedule using the automated system, please call or email us to set up a new appointment. Generally, email is the fastest method of communication for our office. Please be aware that 2 or more “no show” appointments may result in your discharge from our practice; In such an instance, you will receive an original discharge letter and signed by Bruce Cleeremans MD for your record. All discharge letters will be sent out to the home address on file within 7 business days via USPS mail.

OPEN PAYMENTS DATABASE

Pursuant to Assembly Bill (AB) 1278, we are required to provide you with a notice regarding the Open

Payments Database, which is managed by the US Center for Medicare & Medicaid Services, or CMS. The Open Payments Database is a federal tool used to search payments made by drug companies and/or medical device companies to physicians and/or teaching hospitals. This tool can be found at

https://openpaymentsdata.cms.gov

OTHER ADMINISTRATION FEES

We do charge for the completion of paperwork and for medical record requests. Our fees cover administration such as review of your documents, completion and signature of forms, and total time involved for staff/provider. The fees listed below are subject to change based on the quantity of time, pages, questions, or total work needed to complete your request: Generally, our administration fees are as follows:

DMV Forms/Parking Placard $15

Other Disability Forms $25

EDD Forms $40

Medical Records (1-15pages) $15

Medical Records (15-50pages) $25

Medical Records (50 + pages) $50