I voluntarily consent to receive medical and health care services at The Center for Cancer and Blood Disorders (TCCBD) provided by physicians, employees and such associates, assistants, and other health care providers, as my physicians deem necessary. I understand that such services may include diagnostic procedures (such as lab and x-rays), examinations, and treatment that may include chemotherapy and/or radiation therapy and services that may assist me with receiving benefits or services from an outside agency. This consent is valid for so long as I am a patient of TCCBD, including for each and all visits, unless and until revoked by me in writing. Please be informed Texas law allows a patient to be tested for possible exposure to the Human Immunodeficiency Virus (HIV), the virus associated with AIDS, in the following situations: 1) to screen blood, blood products, organs or tissues to determine suitability for donation; 2) if another individual is accidentally exposed to a patient's blood or body fluids, such as through a needle stick (any such test shall be conducted pursuant to TCCBD's infectious disease protocol); or 3) if a medical or surgical procedure is to be performed which could expose health care workers to the patient's blood or body fluids. This disclosure is to inform you that you may be tested, at the expense of TCCBD if any of these situations occur during your treatment period. I understand that no warranty or guarantee has been made to me as to result or cure. I certify that this form has been fully explained to me, and that I have read it or had it read to me*, and that I understand its contents.

I authorize The Center for Cancer and Blood Disorders to disclose my health information for the purpose of continued care, claims processing or other related needs. I authorize The Center to obtain health records from other providers as needed for my continued care. Any other use of this information requires written consent.

FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS: In consideration for receiving medical or health care services, I hereby assign my right, title, and interest in all insurance, Medicare, Medicaid, patient assistance programs, or other third-party payer benefits for medical or health care services otherwise payable to me to The Center for Cancer and Blood Disorders. I also authorize direct payments to be made by Medicare/Medicaid and/or my insurance company patient assistance programs, or other third- party payer, up to the total amount of my medical and health care charges, to The Center for Cancer and Blood Disorders. I agree to pay all charges for medical and health care services not covered by or which exceed the amount estimated to be paid or actually paid by Medicare/Medicaid, my insurance company, or other third-party payer and agree to make payment as requested by The Center for Cancer and Blood Disorders. Copayments are due at time of service. However, I understand I may be responsible for additional coinsurance and/or deductibles as determined by my insurance company once they have paid my claim. I understand that if I am not able to pay my balance in full, I am responsible for contacting The Center’s billing office and/or financial counselors to discuss a payment schedule. If I fail to make payments as agreed upon, my account may be referred to a professional collection agency and/or attorney. I understand I will be responsible for all costs incurred, including attorney’s fees and court costs if applicable. In the event I submit payment by check and the bank returns the check unpaid for any reason, TCCBD will add $25 to my original balance. I certify that the information I have provided in connection with any application for payment by third-party payers, including Medicare/Medicaid, is correct and that it is my responsibility to notify The Center of changes to my address, telephone number, primary care physician, or insurance carrier.

At The Center for Cancer and Blood Disorders, we are proud to bring together a team of highly qualified professionals to provide you the best possible care. Nurse Practitioners and Physician Assistants, that have a great deal of training and experience in adult medicine and oncology, are part of that team. They work very closely with the physicians and communicate your needs. They are well qualified to manage patient care in the clinic or the hospital. The NPs and PAs allow us to increase our attention to your healthcare needs. We have the utmost confidence in our Nurse Practitioners and Physician Assistants. However, you do have a right to request to see your physician personally and we will honor your request. Always be assured we are committed to providing you excellent care with compassion and respect. The Center for Cancer and Blood Disorders physicians. ~Prasanthi Ganesa, MD Medical Director

VII. ACKNOWLEDGEMENT AND REQUESTED RESTRICTIONS. By signing below, you acknowledge that you have received this Notice of Privacy Practices prior to any service being provided to you by the Practice, and you consent to the use and disclosure of your medical information as set forth herein except as expressly stated below. By signing below, you acknowledge that you have received the Notice of Patient Bill of Rights and Responsibilities and that you understand your rights and responsibilities as a patient with this practice.

I hereby authorize the release of my records to: The Center for Cancer and Blood Disorders 800 W. Magnolia Ave Fort Worth, TX 76104 Telephone number: 817-759-7000 Fax No. 817-333-016