A. Medical Power of Attorney (MPOA) Declaration: A representative of Integrated Premier Group Specialty, LLC is required to verify whether a patient has an active MPOA making medical decisions on their behalf. Whether a patient has one or not, IPGS is required to receive written consent from Patient/ MPOA before evaluation or treatment can be rendered.

B. Financial Responsibility: I hereby authorize Integrated Premier Group Specialty, LLC to bill my insurance company for any and all services rendered and for the insurance to pay IPGS all proceeds or benefits directly.

C. Privacy Agreement- HIPAA Notice of Privacy Practices; Patients’ Rights and Responsibilities: By signing this document I acknowledge I have been educated of the Privacy Agreement – HIPAA Notice of Privacy Practices for Integrated Premier Group Specialty, LLC, and have been provided a copy. I may also obtain a copy upon request by calling the office of IPGS at 480-718-0568.

D. Term of the Agreement and Consent: This Agreement and Consent remains effective from the date signed, and includes all future services pertaining to the patient, until Patient/Guardian/MPOA cancels consent for treatment in writing. I understand and agree that IPGS reserves the right to make changes to this agreement and that I, the Patient or Guardian/MPOA will be notified in writing prior to any changes taking effect.

My electronic signature below certifies I or my Guardian/MPOA) have read and agree with all of the notices, disclosures, and consents herein including the Privacy Agreement, Terms of this Agreement and Consent, Release All Liability and Care-Giving Obligations. I (my Guardian/MPOA) also provide consent for treatment to Integrated Premier Group Specialty, LLC, and authorize IPGS to bill my insurance for all services provided.