A. Authorization to Treat

By agreeing to this document I hereby authorize the staff of MyKinHealth Private Limited (MyKinHealth) to provide my registered family members with all medical treatment. I agree to inform MyKinHealth, if I have any concerns about medical treatment to my ward at the time services are being rendered. I agree to be a health care proxy for my beneficiary and grant MyKinHealth, and its employees the right to treat my ward.

B. Release of Information

The medical records concerning patient care are the property of MyKinHealth, and are maintained for the benefit of the patient.

I hereby authorize MyKinHealth to release information and or copies of my medical records to physicians, any guarantor of payment on my account, insurance companies for which I have assigned benefits for my treatment of care.

This includes authorization to release information pertaining to:

- psychiatric and or psychological care,
- alcohol and/or substance abuse,
- Serologic test results (including but not limited to Acquired Immune Deficiency Syndrome or positive HIV results).

I authorize the provider to use all available means of communication to transmit such information, including electronic mail or electronic fax transmissions.

C. Agreement to Pay Service Fees

I acknowledge and agree that I am responsible for and will pay for all regular charges, which are contained in the applicable MyKinHealth pricelist (‘Price List’) which is in effect on the dates of services rendered, for items or services and treatment provided to me, including any amount not paid by my insurance plan. I understand that I can request additional information about charges for procedures, devices, pharmaceuticals, and other items or services, or can obtain a non-binding estimate prior, or subsequent, to signing this agreement. I understand that some items or services that MyKinHealth or is affiliates, may provide to me may not be covered by my insurance carrier, and I agree to be personally responsible for any such non-covered items or services or items or services in excess of the limits in my member benefit agreement. Examples of items or services that may be deemed to be no covered include cosmetic, transplant, certain durable medical equipment, personal convenience items, private nursing duty, sitter services, and certain medical supplies. I understand that I am personally responsible for any item or service determined by my third party payer (my insurance company) to be experimental, investigational, or to be non-covered for any other reason.

I understand that I am personally responsible for any non-covered Medicare, items or services that are listed on the financial responsibility for non-covered items or services form.

I understand that I am personally responsible for deductibles and co-insurance established by my member benefit agreement, including those required for in- network laboratory and other ancillary services or items.

I hereby agree that if MyKinHealth has agreed to bill my insurance or other third- party carrier, it has agreed to do so as a courtesy, and that MyKinHealth has the right, should MyKinHealth deem it advisable, to demand payment in full from me at any time prior to full payment from any insurance or third-party carrier, unless MyKinHealth and my insurance company or third-party carrier have agreed that I will not be billed.

I understand and agree that I have been advised that I may be billed by MyKinHealth and that this Assignment of Benefits and Agreement to Pay applies to any and all MyKinHealth physician services and both inpatient and outpatient MyKinHealthaccounts.

If a delinquent account referred for collection, I agree to pay the reasonable attorney's fees, court costs and/or collection agency fees associated with the collection process.


I hereby authorize and request all insurance carriers, health maintenance organizations or managed care organizations with which I have coverage, to pay directly to MyKinHealth or its affiliates, any and all benefits due under the terms of my policy for items or services provided by MyKinHealth, including any settlements or judgments for such items or services. If my health insurance will not allow direct payment to MyKinHealth, I agree to immediately forward to MyKinHealth all health insurance payments I receive for my care and treatment at MyKinHealth.

We accept Cash, Checks, and Credit/Debit Cards. In the unlikely event that your check is returned unpaid, you understand and agree that your check will be collected electronically or redeposit by paper draft. We will electronically collect the maximum returned check processing charge allowable by state law. I have read and understood the terms and agree to adhere the same.