As an individual receiving orthotic and prosthetic services from our company, let it be known and understood that you have the following rights:

1. To select those who provide you with orthotic and prosthetic services.
2. To receive the appropriate or prescribed service professionally without discrimination relative to your age, sex, race, religion, ethnic origin, sexual preference, or physical or mental handicap.
3. To be dealt with and treated with friendliness, courtesy, and respect by each and every individual representing our company who provides treatment or services for you, and be free from neglect or abuse, be it physical or mental.
4. To assist in developing and planning your health care program that is designed to satisfy, as best as possible, your current needs.
5. To be provided with adequate information from which you can give your informed consent for the commencement of service, the continuation of service, the transfer of service to another health care provider, or the termination of service.
6. To express concerns or grievances or recommend modifications to your service without fear of discrimination or reprisal.
7. To request and receive complete and up-to-date information relative to your condition, treatment, alternative treatments, or risks of treatment.
8. To receive treatment and services within the scope of your health care plan, promptly and professionally while being fully informed of our company's policies, procedures, and charges.
9. To refuse treatment within the boundaries set by law and receive professional information relative to the ramifications or consequences that will or may result from such refusal.
10. To request and receive data regarding treatment, services, or costs thereof privately and with confidentiality.
11. To request and receive the opportunity to examine or review your medical records.

I have received and understand the rights afforded me as a patient/client.

I, (Inital Above) do hereby irrevocably consent to and authorize A Step Ahead, LLC ("ASA"), its members, agents, employees, and personnel who are acting on behalf of ASA, to use my photograph, video image, or other likeness for purposes related to the promotion, publicity, and marketing of ASA, without compensation to me.

I understand my photograph, video image or other likeness may be copied and distributed by means of various media including, but not limited to, placement on websites, Facebook, Twitter, Instagram, TikTok, Pinterest, Google, YouTube, and other electronic delivery or publications, video presentations, printed brochures, mailings, and for display inside ASA offices and facilities.

I acknowledge that ASA has the right to make one or more photographs, audio and/or video recordings, or other electronic reproductions of my image, voice or performance in accordance with this agreement. I waive any right to inspect or approve the finished product, or any material in which ASA may eventually use the photographs.

I relinquish and give ASA all rights, title and interest in and to the photographs and video recordings, including any copyright therein. This consent and release shall be binding upon my heirs, successors, assigns and legal representations.

I understand that although ASA will endeavor to use my photograph, video image, or likeness in accordance with standards of good judgment, ASA cannot warrant or guarantee that any further dissemination of my photograph, video image, or likeness will be subject to ASA supervision or control. Accordingly, I release ASA from any and all liability related to dissemination of my photograph, video image, or likeness, reproduction, distribution, and display of the photographs in print or any and all other media, and any alteration, distortion or illusionary effect, whether intentional or otherwise, in connection with said use.

This release absolves ASA of any responsibility to maintain HIPAA standards regarding any full-face images, video recordings, or other likenesses, of myself. ASA will continue to maintain HIPAA standards of all other protected healthcare information.

I also understand that upon my written request, I may revoke this Authorization at any time and ASA will cease from further reproducing my photograph or video image or other likeness for any further purpose. However, I understand that my right to revoke this Authorization does not extend to ASA uses of my photograph, video image, or other likeness that have already been created prior to the date of written notice of my revocation of this authorization.

I have read and understand the conditions of this consent form.

Our goal is to provide quality care in a timely manner. In order to do so, A Step Ahead has implemented a new appointment cancellation policy effective January 1, 2011. This policy will enable us to better utilize available appointments for our patients in need of prosthetic care.

Cancellation of an Appointment:
In order to be respectful to other patients, please call the facility promptly if you are unable to attend an appointment. This will allow us to reallocate the appointment time to someone who is in urgent need of treatment. If it is absolutely necessary to cancel your scheduled appointment, please call the office at least 24 hours prior to your scheduled appointment.

How to Cancel Your Appointment:
To cancel appointments, please call our office at (516) 681-3484 and speak to the receptionist during our office hours (Monday through Thursday, 7:30 AM to 4:00 PM and Friday 7:30 AM - 2:30 PM). If you call after hours or do not reach the receptionist, you may leave a detailed message on the voice mail about your cancellation. You may not cancel via email.

Late Cancelations:
Late cancellations (less than 24 hours prior to your scheduled appointment) will be considered a "no show" (see below).

No Show Policy:
A "no show" is someone who misses an appointment without canceling it more than 24 hours prior to a scheduled appointment. No-shows inconvenience other patients who need access to prosthetic care in a timely manner. The first time a patient no-show an appointment, they will be sent a letter alerting them to the fact that they have failed to show up for an appointment and did not cancel the appointment at least 24 hours prior to their scheduled appointment. A copy of the letter will be placed in the patient file. Additional failures to present at the time of a scheduled appointment will result in an administrative fee of $50.00 for each occurrence, billed to the patient’s account. If you have any questions regarding this cancellation policy please don't hesitate to ask.

A Step Ahead is committed to providing you with the highest quality prosthetic and orthotic care. If you have any questions about our professional fees, please speak to our Insurance Task Force. Your understanding of our Financial Policy is important to our relationship.

Coinsurance & Deductible

I acknowledge my responsibility to pay any applicable co-insurance and deductible to A Step Ahead in a timely fashion.

Balances

The difference between what A Step Ahead bills and what an insurer may reimburse can result in a balance due. Insurers reimburse at their "usual and customary rate”, which is generally based upon what prosthetists/orthotists in the same geographic area bill to their patients. The insurer's "usual and customary rate" may be the same as or lower than A Step Ahead's charges. Your insurer's "usual and customary rate does not supersede A Step Ahead's charge, and any difference between what your insurer pays and A Step Ahead's charge may be the patient's responsibility.

I acknowledge my responsibility to pay any and all unpaid balances to A Step Ahead in a timely fashion.

I further agree and expressly consent that any dispute with A Step Ahead shall be governed and construed in accordance with the laws of New York, without regard to New York's choice-of-law principles, and all claims sounding in contract, tort, or otherwise, shall likewise be governed by the laws of New York excluding New York's choice-of-law principles.

If you have not received prior approval for the service or authorization has been denied, you are fully responsible for all charges, if your insurance company does not agree to pay. In addition, you will be responsible for all deductibles, co-insurance, and co-payments or for any service not covered by your insurance plan.

I have read and understand this information. I understand that my insurance company may deny coverage or send a check directly to myself as the patient. I agree to be fully responsible for all charges including attorney fees, costs of collection and for any payment not paid within thirty days liable for interest at the rate of___. (The court rate is 9% on a judgment). I understand that A STEP AHEAD PROSTHETICS is relying on this promise and is rendering services without requiring payment at the time of service based on such reliance.

A Step Ahead Prosthetics is a non-participating provider with your insurance carrier. As a result, your carrier may send payment for services rendered by us, directly to you. These payment(s) are property of A Step Ahead Prosthetics. You are responsible for forwarding any and all insurance payment(s) that indicate A Step Ahead Prosthetics as the provider, to us within 15 days of receipt. Your account will remain open until we receive these payments, and failure to comply with the forwarding of payment can result in legal action. We recommend that you photo copy any payment that you receive for your records, before forwarding to us.

I (Sign Name Below) acknowledge that I will be held solely responsible for the amount paid by my insurance carrier, as well as the full amount of the submitted charges by A Step Ahead Prosthetics, with interest.

I have received and thoroughly reviewed A Step Ahead Prosthetics & Orthotics' Notice of Privacy Practices. I understand and acknowledge that the privacy notice details how my protected health information ("PHI") can be used by A Step Ahead, what my rights are, and what A Step Ahead's duties are to me to protect my PHI.

I, (Print Above) hereby authorize A Step Ahead Prosthetics to communicate and release any and all pertinent medical information including diagnosis, records, examinations to any of the following individuals:

1. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
2. The Release of Information will remain in effect until terminated by me in writing. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
3. I understand that my treatment, payment, enrollment, or eligibility benefits will not be conditioned on whether I sign this authorization.
4. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Please be advised that when visiting our facility for an appointment, you must always sign in.

Whenever items/repairs are delivered to you, you must sign a delivery sheet that will list every item that you have received. This is your responsibility! If you do not sign a delivery sheet, you become liable. Not signing could void warranties and/or make you accountable for costs and payments.

Please remember that when you receive any new item, you must sign for it. If you are unsure if you have to sign, please ask at the front desk or ask to speak to our billing coordinators. Someone will be able to advise you of your responsibilities.

If you have any questions regarding this policy, please do not hesitate to ask.

We have a 24-hour, 365-day/year hotline that you can call if an emergency arises. We can always create appointments for emergency situations.

A prosthesis is a mechanical device. Like any mechanical device, it can malfunction. When this happens, it is imperative that you receive prompt emergency triage from our prosthetic staff.

A true prosthetic emergency is something that cannot wait until the next business day.
The following are examples of prosthetic emergencies:

A broken or malfunctioning prosthetic component (knee, foot, etc.).

You are unable to take the prosthesis off after numerous attempts.

If you have fallen on your residual limb and/or you have significant pain and/or swelling, or there is a significant irritation or skin breakdown on your residual limb, you should contact your doctor immediately or seek treatment at an emergency room.

If you need to call due to an emergency after our regular business hours, call our regular office number (516) 681-3484, follow the voice prompts to the emergency mailbox, leave a detailed message and slowly repeat the phone number where you can be reached. Our phone system will then page a prosthetist so that you can get assistance as soon as possible.

I have received a copy of this Prosthetic Emergency Notice and understand the guidelines contained in it.

Assignment of Insurance Benefits - Appointment as Legal Authorized Representative

I hereby assign all applicable health insurance benefits and all rights and obligations that I have under my health plan to A Step Ahead Prosthetics (hereinafter "My Authorized Representatives") and I appoint them as my authorized representative with the power to:

• File medical claims with the health plan
• File appeals and grievances with the health plan
• Institute any necessary litigation and/or complaints against my health plan naming me as plaintiff in such lawsuits and actions if necessary (or me as guardian of the patient if the patient is a minor)
• Discuss or divulge any of my personal health information or that of my dependents with any third party including the health plan

I certify that the health insurance information that I provided to Provider is accurate as of the date set forth below and that I am responsible for keeping it updated.

I am fully aware that having health insurance does not absolve me of my responsibility to ensure that mv bills for professional services from Provider are paid in full. I also understand that I am responsible for all amounts not covered by my health insurance, including co-payments, co-insurance, and deductibles.

Authorization to Release Information

I hereby authorize My Authorized Representatives to: (1) release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process all insurance claims. This order will remain in effect until revoked by me in writing.

ERISA Authorization

I hereby designate, authorize and convey to My Authorized Representative to the full extent permissible under law and any applicable insurance policy and/or employee health care benefit plan: (1) the right and ability to act as My Authorized Representative in connection with any claim, right, or cause of action including litigation against my health plan (even to name me as a plaintiff in such action) that I may have under such insurance policy and/or benefit plan; and (2) the right and ability to act as My Authorized Representative to pursue such claim, right or cause of action in connection with said insurance policy and/or benefit plan (including but not limited to the right and ability to act as my Authorized Representative with respect to a benefit plan governed by the provisions of ERISA as provided in 29 C.F.R §2560.5031(b)(4) with respect to any healthcare expense incurred as a result of the services I received from Provider and, to the extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement, and any other applicable remedy, including fines. I authorize communication with the Provider and their authorized representatives by email and my email address is (please write email below) I understand I can revoke this authorization in writing at any time.

A photocopy of this Assignment/Authorization shall be as effective and valid as the original.