ASSIGNMENT OF BENEFITS

By signing below (electronically or in person), I — or as the parent or authorized guardian signing on behalf of a minor or incapacitated individual — agree that: • The information I am giving you is correct. Cloud Health Medical Group, P.A., Cloud Health Medical Group of California, P.C., Cloud Health Medical Group of New Jersey, P.A., and Cloud Health Medical Group of Kansas, P.C. (collectively "Cloud Health Medical") and my doctor (or the patient's doctor) may release or share any information needed to process claims, including with a division of state or local government authorized to reimburse such claims. • Cloud Health Medical and those providing care shall be paid or assigned benefits on the patient's behalf. • I will cooperate with and provide documentation to the insurance company or other third-party payer as needed to process claims. • I (or the patient, as applicable) am responsible for any costs not covered by benefits, including non-covered services, deductibles, and co-insurance. If signing as a Parent or Authorized Guardian: By completing this form online, I represent and warrant that I am the parent, legal guardian, or otherwise duly authorized representative of the patient named herein, and that I have full legal authority to execute this Agreement on the patient's behalf. I acknowledge that my electronic signature carries the same legal force and effect as a handwritten signature.

I request and agree that any benefits due for treatment by all insurance companies or other third-party payers responsible for the patient's care shall be paid or assigned to Cloud Health Medical. This includes any insurance company settlements related to the patient's treatment. If the insurance company or other payer will not pay Cloud Health Medical directly, I will immediately forward any payments received to Cloud Health Medical.

I understand that the patient's insurance or payer may not cover all costs. I agree that the patient (and I, as guarantor) am personally responsible for: Any costs not covered by insurance or payer, or that exceed benefit limits, including but not limited to: • Self-administered medications (medicines the patient would normally take on their own) • Certain durable medical equipment • Certain medical supplies • Services and supplies that the insurance or payer determines are experimental, investigational, not covered for any other reason, or not medically necessary but that the patient wishes to receive.

If the patient is a beneficiary of a government health program, I agree that neither the patient, the patient's healthcare provider, the affiliated physician practices, nor any of the healthcare organization(s) or provider(s) with whom Cloud Health Medical partners to provide healthcare and pharmacy services will submit a claim for reimbursement to any federal or state healthcare program except Medicare Advantage plans for the costs of the services and products provided through the Services. Submission of claims to Medicare Advantage plans is expressly permitted. All other government program claims (e.g., Medicare Part B (FFS), Medicaid, Tricare, Veterans Affairs) are strictly prohibited.

Cloud Health Medical and my doctor (or the patient's doctor) may release or share any information needed to process claims, including with a division of state or local government authorized to reimburse such claims. This authorization extends to all insurance companies or other third-party payers responsible for the patient's care.

By submitting this form online, I acknowledge and agree that: My electronic signature constitutes my legal signature and is binding to the same extent as a handwritten signature under applicable law, including the Electronic Signatures in Global and National Commerce Act (E-SIGN) and applicable state electronic signature laws. I authorize Plus Wellbeing to bill my insurance (if applicable) and I agree to be responsible for applicable copays, coinsurance, deductibles, non-covered services, and any disclosed fees. I have had the opportunity to read this Agreement in full prior to signing. If I am signing as a parent or authorized guardian, I confirm my authority to do so and agree to provide documentation of such authority upon request.