MyPhoneTherapies, LLC - New Patient Registration

4. Assignment and Authorization

I hereby authorize MyPhoneTherapies, LLC, LLC, through its networks, contractors, and/or its employees (herein "MPT") to supply me with any healthcare, mental health, functional assessment, monitoring, and electronic communication services, transportation, medications, and supplies (herein defined as "Services"). I hereby authorize my insurance company and/or attorney to pay directly to MyPhoneTherapies, LLC ("Assignee") such sums as may be due and owing Assignee for Services provided to me by MPT, both by reason of accident or illness, and by reason of any other bills that are due Assignee, and to withhold such sums from any auto insurance benefits, medical payments, Personal Injury Protection (PIP), No-Fault benefits, MedPay, workers' compensation, premises liability, maritime or longshore insurance, or any other insurance benefits obligated to reimburse, or from any settlement, judgment, or verdict on my behalf, as may be necessary to adequately protect said Assignee.

I hereby give a lien to said Assignee on any and all insurance benefits named herein and any and all proceeds of any settlement, judgment, or verdict which may be paid to me as a result of the injuries or illness for which I have received Services from Assignee. This agreement is assignable by Assignee. This assignment of rights and benefits applies to the extent of the Assignee's Services provided to me in accordance with applicable state statute(s). I hereby acknowledge that this agreement acts as a letter of protection for the Assignee.

I authorize MPT and its assignees to release any information in its possession regarding me, my claim(s), my case, or any Services provided to me by MPT to any insurance company, law firm, payer, assignee, and their employees, representatives, and agents as necessary to facilitate administrative, billing, collection, or claim-related processes.

In the event that any insurance company obligated to make payments for Services rendered by Assignee refuses or reduces such payments, I hereby assign and transfer to Assignee any and all causes of action against such company and authorize Assignee to administer such matters as permitted under this agreement and applicable law.

I acknowledge that MPT complies with all applicable national, state, and local privacy laws and regulations, including but not limited to HIPAA. I confirm that I have had the opportunity to review MPT privacy policies prior to signing this document.

5. Personal Health Information Disclosure and Use (PHI) / Patient Privacy

This notice describes how MyPhoneTherapies, LLC ("MPT") may use and disclose your protected health information ("PHI") to carry out treatment, payment, or healthcare operations, and for other purposes permitted or required by law, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and applicable state privacy laws. It also describes your rights to access and control your protected health information. MPT may change the terms of this notice at any time. The revised notice will be effective for all PHI we maintain at the time of the change. You may request a copy of any revised Notice of Privacy Practices by contacting us by email, through the patient portal at myphonetherapies.com, or by written request.

Your PHI will be used or disclosed only for the purposes listed below, or as otherwise authorized by you in writing. Any specific written authorization you provide may be revoked at any time by submitting a written request to MPT.

• Health Care Provider — PHI may be used and disclosed to your physician or other healthcare provider who is also treating you, and to MyPhoneTherapies, LLC and its assignees when needed for coordination of care, functional assessment monitoring, or administrative purposes.
• Payment — Your PHI may be used and disclosed for submission of claims to your insurance carrier, workers' compensation carrier, or legal representative, including MyPhoneTherapies, LLC and its assignees, for the purpose of obtaining payment for Services rendered.
• Care Operations — Your PHI may be used and disclosed to MPT staff members, contracted clinicians, and business associates, including assignees, for the purpose of providing, managing, and improving services.
• As Required by Law — Your PHI may be used and disclosed to any person or agency as required by applicable federal, state, or local law.
• Court Orders and Legal Proceedings — Your PHI may be disclosed as part of a court proceeding, in response to a subpoena or court order, or as otherwise required by law.
• Appointment and Assessment Reminders — You may be contacted by phone, SMS/text, email, or patient portal for reminders related to your scheduled assessments, monthly check-ins, or clinician review status.
• Family & Friends — Unless you object, we may disclose relevant PHI to a family member or close personal friend when directly relevant to their involvement in your care or in an emergency.
• Victims of Abuse, Neglect, or Domestic Violence — Your PHI may be disclosed to authorized persons from state or federal agencies as required by law.
• Emergency Situations — Your PHI may be disclosed to a family member, personal representative, or emergency personnel in the event of a medical emergency.
• Workers' Compensation and Maritime Claims — We may disclose your PHI as authorized or required by laws relating to workers' compensation, occupational health, maritime, or similar programs.
• Business Associates and Contracted Clinicians — We may disclose your PHI to business associates or contracted clinicians with whom MPT has entered into a Business Associate Agreement (BAA), solely for the purpose of providing services on our behalf and in compliance with HIPAA.

Your Rights: You have the right to request access to, a copy of, an amendment to, or a restriction on the use and disclosure of your PHI, to the extent permitted by law. You also have the right to request an accounting of disclosures. All such requests must be submitted in writing to MPT.

Breach Notification: In the event of a breach of your unsecured PHI, MPT will notify you in accordance with applicable HIPAA Breach Notification Rules, without unreasonable delay and in no case later than sixty (60) calendar days following discovery of the breach.

Right to File a Complaint: If you believe your privacy rights have been violated, you have the right to file a complaint with MPT or with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR), at www.hhs.gov/ocr or by calling 1-800-368-1019. MPT will not retaliate against you for filing a complaint.

By signing below, I acknowledge that I have received and reviewed this Notice of Privacy Practices. I authorize the use and disclosure of my PHI as described herein. I understand my rights as stated above.

6. Terms of Use

Thank you for using the MyPhoneTherapies, LLC platform and Website (the "Website"). The following Terms of Use Agreement (the "Agreement") governs your use of the Website and all related services. Throughout this Agreement, the term "MPT" refers to MyPhoneTherapies, LLC, its owners, officers, agents, representatives, associates, business associates, employees, and contractors, including but not limited to independently contracted clinicians, reviewers, and healthcare professionals.

Please read these Terms of Use carefully before using this Website or submitting any information. By using this Website, you agree to be bound by this Agreement. If you do not agree to these Terms of Use and the Privacy Policy, please exit and do not use this Website or its services.

You agree to comply with all applicable laws in connection with your use of the Website and any limitations set forth in any written or on-screen notice from MPT. You agree that you will not use this Website for any purpose that is unlawful or prohibited by this Agreement.

You agree and consent to the terms of the MPT PHI policy and all applicable regulatory guidelines, which are available on this Website.

Electronic & Telephonic Communications: Electronic and Telephonic Communications ("ETC") include telephone, text/SMS messages, emails, secure forms, video, patient portal communications, this Website, facsimile, scheduling platforms, and other electronic or telephonic means. By visiting or communicating through this Website or via ETC, you consent to receive communications from MPT via ETC. You agree that all agreements, notices, disclosures, and other communications provided to you via ETC satisfy any legal requirement that such communications be in writing.

Independent Contractor Clinicians — Limitation of Liability: MPT provides a technology-based assessment monitoring platform. Clinical reviews, interpretations, and sign-offs are performed by independently contracted, licensed clinicians ("Contracted Clinicians") who are not employees or agents of MPT. MPT is not responsible for, and expressly disclaims any and all liability arising from, any act, omission, clinical decision, error, or negligence of any Contracted Clinician. Each Contracted Clinician is solely responsible for their own professional conduct, clinical judgment, and compliance with applicable professional standards and licensing requirements. Any claims arising out of clinical services must be directed to the individual Contracted Clinician and their applicable professional liability insurer. By using this Website, you acknowledge and agree to this limitation.

No Medical Advice: The assessment tools, reports, and information provided through this Website and platform are for monitoring and documentation purposes only and do not constitute medical diagnosis, medical advice, or a treatment plan. MPT does not practice medicine. Any information provided by MPT, its staff, contractors, or representatives through any means, including ETC, is for general informational guidance only and does not establish a physician-patient relationship. You are encouraged to consult a qualified, licensed healthcare provider for all medical decisions. If you are experiencing a medical emergency, call 911 or go to the nearest emergency room immediately.

Indemnification: By using this Website, you agree to indemnify and hold harmless MPT, its owners, officers, employees, and contractors from any claims, damages, costs, or liabilities, including reasonable legal fees, arising out of: (a) your use of the Website or platform; (b) your violation of these Terms of Use; (c) any infringement of intellectual property or other rights; or (d) any false or inaccurate information you provide in connection with your registration or use of Services. This indemnification does not apply to claims arising solely from the gross negligence or willful misconduct of MPT.

7. Electronic Communications Consent

MyPhoneTherapies, LLC ("MPT") communicates with patients and authorized representatives through electronic and telephonic means, including but not limited to: text/SMS messages, email, patient portal notifications, telephone calls, video, secure online forms, and other electronic channels (collectively, "Electronic Communications"). By registering and using the MyPhoneTherapies, LLC platform, you consent to receive Electronic Communications from MPT regarding your assessments, monthly check-in reminders, clinician review status, report availability, appointment scheduling, and any other matters related to your care and Services.

You agree that all agreements, notices, disclosures, reports, and other communications provided to you by MPT via Electronic Communications satisfy any legal requirement that such communications be in writing, to the fullest extent permitted by applicable law.

I hereby consent, acknowledge, and agree to receive current and future Electronic Communications from MyPhoneTherapies, LLC and its providers, which may include but are not limited to: assessment notifications, monthly check-in reminders, clinician review updates, report delivery, and any telehealth, video, telephonic, or secure portal communications that may be offered in connection with my care. I understand that MPT may utilize third-party platforms, including email and SMS services, to deliver these communications and that such platforms comply with applicable HIPAA and data security requirements.

I understand that MyPhoneTherapies, LLC provides assessment monitoring and documentation services and does not provide emergency medical care. If I am experiencing a medical emergency, I will call 911 or go to the nearest emergency room immediately.

I may withdraw my consent to receive Electronic Communications by submitting a written request to MPT. I understand that withdrawal of consent may limit my ability to use certain features of the platform, including receiving clinician review notifications and assessment reminders.

8. Authorization for Release of Medical Records and Information

I authorize all healthcare providers, physicians, hospitals, clinics, mental health professionals, medical staff, and attorneys to furnish any and all information and medical records regarding me to MyPhoneTherapies, LLC and its assignees, including records relating to accident injuries, functional assessments, disability evaluations, psychiatric, psychological, neuropsychological, and all mental health records, as well as any prior medical history relevant to my injuries or current conditions.

I authorize MyPhoneTherapies, LLC and its assignees to release any and all information and medical records regarding me — including records relating to accident injuries, functional and disability assessments, psychiatric, psychological, and all mental health records — to those parties necessary to process, support, and/or collect from my insurance claim(s), workers' compensation claim(s), maritime or longshore claim(s), premises liability claim(s), or any other claims related to my healthcare services and/or accident-related injuries.

I authorize MyPhoneTherapies, LLC and its assignees to release any and all information and medical records regarding me, including accident injury documentation, assessment results, monthly progress reports, clinician review records, and mental health records, to all healthcare providers involved in my care and their representatives, and to my attorney(s), paralegal(s), and their authorized representatives.

I authorize MyPhoneTherapies, LLC and its assignees to release assessment results, progress reports, and clinician-reviewed documentation to any insurance company, adjuster, or claims representative handling my accident-related insurance claim, as reasonably necessary to support the processing and resolution of such claim.

I agree that this authorization shall cover all medical services rendered by MyPhoneTherapies, LLC and its contracted clinicians, with no limitation on dates or history of injury and/or illness, and shall remain in effect until revoked by me in writing. I understand I may revoke this authorization at any time by submitting a written request to MPT, except to the extent that MPT has already acted in reliance upon it. I agree that a photocopy, electronic copy, or digitally transmitted version of this authorization may be used in lieu of the original and shall carry the same legal effect.

9. Patient History

Conditions Related to the Accident

Check all symptoms you have experienced since the accident.