Assignment of Benefits

• "Circle Medical" means, collectively, Circle Medical Care Group, P.A., a Florida professional association; Circle Medical Group of California, a California professional corporation; Circle Medical Care Group of New Jersey, P.C.; and Circle Medical Care of New York, P.C.
• "Cloud Health Medical" means collectively, Cloud Health Medical Group, P.A., a Florida professional association; 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.
• "Medical Group" means the applicable Circle Medical or Cloud Health Medical entity that provides services to the patient, as identified in the patient's records and/or billing statements.
• "Providers" means the physicians, nurse practitioners, physician assistants, and other licensed professionals who furnish services on behalf of the Medical Group.

By signing below (electronically or in person), I agree:

• The services provided through this platform are intended only for individuals who are 18 years of age or older. By signing this Assignment of Benefits, I represent and warrant that the patient meets this requirement.
• I am either the patient signing on my own behalf or the patient's legally authorized representative with full legal authority to execute this Assignment of Benefits on the patient's behalf.
• I represent and warrant that the information provided by me is accurate and complete.
• I understand that my care will be provided by the Medical Group. The Medical Group and its Providers may use and disclose information as necessary to process claims, including with a division of state or local government authorized to reimburse such claims.
• I will cooperate with and provide documentation to the insurance company or other third-party payer as needed to process claims.
• I am responsible for cost-sharing amounts, including deductibles, copayments, and coinsurance. If I am signing as the patient's legally authorized representative, I understand that such financial responsibility applies to the patient and/or guarantor as permitted by law.

I hereby assign and authorize payment of any applicable insurance or other third-party benefits directly to the Medical Group (as defined above, and for clarity includes Circle Medical and Cloud Health Medical) for services rendered, including payments otherwise payable to me. This assignment applies to all insurance companies and other third-party payers responsible for payment of the patient's care and remains valid for all services provided by the Medical Group unless revoked in writing.

This assignment includes the right to submit claims, receive payments, obtain explanations of benefits (EOBs), appeal claim denials, pursue administrative remedies on my behalf, and communicate directly with my insurance plan regarding coverage and payment. This assignment also includes any payments made in connection with claims, settlements, or judgments related to the services provided.

If payment is made directly to me, I agree to promptly forward such payment to the Medical Group that rendered the services.

I understand that insurance or other payer may not cover all costs. I agree that I am personally responsible for any costs not covered by insurance or other 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 other payer determines are experimental, investigational, not covered for any other reason, or not medically necessary but that the patient wishes to receive.

For services provided by Circle Medical, if the patient is enrolled in a Medicare Advantage plan or other government-sponsored health plan, billing and payment for services will be handled in accordance with applicable laws, regulations, and plan requirements. Patient responsibility for applicable cost-sharing amounts (including copayments, coinsurance, and deductibles) will be determined in accordance with the patient's health plan and applicable law.

For services provided by Cloud Health Medical, submission of claims to Medicare Advantage plans is expressly permitted. Submission of claims to all other government health programs—including Medicare Part B (fee-for-service), Medicaid, TRICARE, and Veterans Affairs—is strictly prohibited. If the patient is a beneficiary of any such government health program, neither the patient, Cloud Health Medical, nor any affiliated provider or entity will submit a claim for reimbursement to that program for services provided by Cloud Health Medical. Patient responsibility for applicable cost-sharing amounts under Medicare Advantage (including copayments, coinsurance, and deductibles) will be determined in accordance with the patient's plan and applicable law.

I understand and agree that:

• I am responsible for all charges incurred, including services provided by the Medical Group and its Providers, to the extent not paid by insurance, for any reason.
• Payment is due after insurance has processed the claim, unless otherwise agreed.
• If I am signing on behalf of the patient, I may be personally responsible for such charges to the extent permitted by law.
• The Medical Group may bill the patient's insurance on the patient's behalf and may require payment in full in advance, unless otherwise agreed with the insurance company or other payer.
• I may request an estimate of charges based on the Medical Group's pricelist ("chargemaster") in effect at the time of service. Any estimate provided is not a guarantee of actual charges.
• If any balance is referred for collection, I agree to pay all associated costs, including attorney's fees, court costs, and collection agency fees.
• I consent to receive communications from the Medical Group and its Providers, affiliates, agents, and contractors, including debt collectors, regarding care, appointments, and billing related to the patient via phone, text message, or email, including through the use of automatic telephone dialing systems, artificial or pre-recorded voice messages, and other automated technology. I understand that I may opt out of non-essential communications at any time. Message and data rates may apply.
• To the extent permitted by law, the Medical Group may access consumer credit information solely for purposes of collections or evaluation of eligibility for financial assistance.

The following provisions apply to patients receiving services in the states listed below:

California

• For services provided in California, the patient may be entitled to protections under California law, including protections against surprise medical bills.
• Patients have the right to receive a Good Faith Estimate of expected charges upon request.
• Any collection of amounts owed will comply with applicable California consumer protection laws, including the Rosenthal Fair Debt Collection Practices Act.

New York

• For services provided in New York, patients may be protected from surprise billing under New York law.
• Patients have the right to request an estimate of charges for services.
• Billing and collection practices will comply with applicable New York consumer protection laws.

New Jersey

• For services provided in New Jersey, patients may be protected from unexpected out-of-network charges under the New Jersey Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act.
• Patients may request an estimate of charges prior to receiving services.

General (All States)

• To the extent required by applicable law, patients may be entitled to billing protections, including payment plans or other arrangements as required by law.
• Nothing in this Assignment of Benefits is intended to waive any rights or protections provided under applicable federal or state law, including the No Surprises Act.

This Assignment of Benefits is effective April 30, 2026.

By submitting this form online, I acknowledge and agree that:

• My electronic signature is legally binding and has the same force and effect as a handwritten signature under applicable law, including the Electronic Signatures in Global and National Commerce Act (E-SIGN) and applicable state laws.
• I have had the opportunity to read this Assignment of Benefits in full prior to signing.
• This Assignment of Benefits is effective as of the date indicated above.
• If I am signing on behalf of the patient, I represent that I am the patient's legally authorized representative and agree to provide documentation of such authority upon request.