MOOD CLINICAL P.C. FINANCIAL ASSISTANCE POLICY

POLICY

1. This Financial Assistance Policy (this “Policy”) sets forth the standards and processes by which Mood Clinical, P.C. (together with its affiliates, the “Provider”), identifies patients who are uninsured (the “Eligible Patients”) and provides discounted mental health care to such Eligible Patients.

2. No patient will be denied financial assistance because of his or her race, religion, or national origin or any other basis which is prohibited by law. In implementing this policy, the Provider will comply with all applicable federal, state and local laws, rules and regulations

3. The Provider provides all financial assistance and discounts on a consistent and non-discriminatory basis and in an equitable manner so that all patients applying for and/or receiving financial assistance are treated with dignity and respect.

ELIGIBILITY

1. Eligibility Consideration.

   Any patient or responsible party who indicates they are uninsured.

PROCEDURES

Identification of Cases.

1. The Provider will make information about its financial assistance program available on its website and on each bill that is sent out to any patients and will endeavor to inform all Eligible Patients of the financial assistance program and how to utilize such assistance pursuant to this Policy.

2. Patients or their responsible party will be able to attest to their uninsured status when registering for services on the Provider’s website

Patient Responsibility.

1. It is ultimately the patient's responsibility to provide the necessary information to qualify for financial assistance when registering for services via the Provider’s website.

FINANCIAL ASSISTANCE ELIGIBILITY CRITERIA

1. A determination will be made on a patient’s eligibility to receive financial assistance on the provider charges based on the information provided when registering for services via the Provider’s website. For the purposes of this policy, “provider charges” means the full billed charge for all services provided by the provider, including professional services and other ancillary services

2. The level of financial assistance will be based on the eligible patient’s classification as an uninsured patient, in accordance with the below

Uninsured Patients.

1. An “Uninsured Patient” means a patient who does not have any third-party insurance. For the avoidance of doubt, a patient is not considered an Uninsured Patient if they have insurance, but the services they receive from Provider is not covered by their insurance.

2. It is the Provider’s policy to provide all Uninsured Patients with the discounted pricing outlined in Exhibit A.

Financial Assistance Committee.

1. In certain situations, it may be appropriate to grant a patient financial assistance even though the patient's financial situation does not satisfy the requirements set forth in Provider’s Financial Assistance Eligibility Criteria Guidelines.

2. In these situations, the Financial Assistance Application and other pertinent information may be reviewed by the Provider’s Financial Assistance Committee, who will make a determination as to the patient's eligibility for financial assistance

NON-PAYMENT

After a patient's account is reduced by any discounts available under this Policy, the patient or responsible party will be responsible for the remainder of his or her outstanding patient accounts. Patients will be invoiced for any remaining amounts in accordance with the Provider’s Billing & Collections Policy.

The Provider’s Billing & Collections Policy describes in further detail the collection actions that may be taken by the Provider in the event of non-payment of bills.

REASONS FOR DENIAL

1. Certain Services Not Covered.

   The Provider reserves the right to exclude certain services from coverage under this Financial Assistance Policy

EXHIBIT A

PSYCHIATRY AND THERAPY DISCOUNTS AVAILABLE TO UNINSURED PATIENTS

The discounts afforded by the Provider to Uninsured Patients are set forth below.

Discounted rate by service type