PLEASE FAX COMPLETED FORM TO 800-288-5691 Please allow 1 business day for electronic signature activation

PLEASE FAX COMPLETED FORM TO 800-288-5691 December 2015

CONSENT TO ELECTRONIC CONTRACTS AND SIGNATURES

DPM electronic signatures will now be included on one or more of the documents that you create in the SureFit Compliance Portal (the “Portal”). You will need to open, review, sign and elect to electronically sign these document(s), by logging into the portal using your secure login. The document(s), when ready for signature, will be available in the secure email inbox that you have provided, and from which you are responding. You, the DPM, are responsible for: a) keeping your login ID and password secure, b) not allowing others to sign on your behalf, c) reviewing document(s) before electing to sign, you agree to the accuracy of the content, and d) immediately notifying SureFit via email if your password has been compromised. You are responsible for all activity through the Portal that occurs under your login ID and password. You understand by electing to sign the document(s), you agree to the accuracy of the contents of the document(s).

You further acknowledge and agree that: (a) SureFit and you can enter into and sign agreements electronically, including without limitation, subscription agreements, limited liability company agreements, and amendments to agreements (collectively “Agreements”). (b) Your use of a key pad, mouse or other device to type my name, select an item, button, icon or similar act/action, or to otherwise provide instructions to SureFit electronically, or in accessing or making any transaction regarding any Agreement, acknowledgement, consent, terms, disclosures or conditions constitutes your signature (your “E-Signature”), acceptance and agreement the same as if actually signed by you in writing. (c) You agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and SureFit. (d) You will not share your user name, user ID or password credentials for logging into SureFit’s Portal with an third party, and will not authorize any third party to provide an E-Signature in your absence or on your behalf. (e) The parties’ electronic signatures shall be valid and enforceable in accordance with the Electronic Signatures in Global and National Commerce Act (“E-SIGN”), 15 U.S.C. 7001, et seq. (f) All Agreements shall constitute original documents admissible in a court of law when printed from electronic files and records established and maintained by either party in the normal course of business. I, ________________________________, understand, acknowledge and agree to the terms above and give consent for my electronic signature to be used to sign document(s) that will be faxed to the patient’s referring MD/DO. I also verify this to be my secure email address: ___________________________________ Email address

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