I, the undersigned patient (or authorized representative), voluntarily consent to medical care, treatment, and procedures provided by Breathewell Pulmonary Clinic and Dr. Yaneidy Santana, MD, including but not limited to: physical examinations, diagnostic testing (pulmonary function tests, imaging, blood work, sleep studies), medical treatments, telehealth consultations, and any other procedures deemed medically necessary.

I understand that medicine is not an exact science and that no guarantees have been made to me regarding the outcome of any examination, treatment, or procedure. I acknowledge that I have the right to ask questions about any proposed treatment and to refuse treatment at any time.

I authorize the medical staff at Breathewell Pulmonary Clinic to administer care as they determine to be in my best medical interest. I understand that if I am being seen via telehealth, the same standard of care applies, and I consent to the use of secure audio/video technology for my visit.

This consent shall remain in effect for all visits and treatments at Breathewell Pulmonary Clinic unless revoked by me in writing.

I authorize Breathewell Pulmonary Clinic to use and disclose my protected health information (PHI) in accordance with HIPAA for the following purposes:

• Coordination of my medical care with referring physicians, specialists, hospitals, laboratories, and pharmacies
• Submission of claims and communication with my health insurance provider(s) for billing and payment purposes
• Quality assurance, compliance, and healthcare operations as permitted by law

I understand that my medical records may contain information related to mental health, substance abuse treatment, or HIV/AIDS-related testing, and I specifically authorize the release of such information to the extent necessary for my care and treatment.

I understand that I may revoke this authorization at any time by submitting a written request to Breathewell Pulmonary Clinic. This authorization expires one year from the date of signature or upon written revocation, whichever occurs first.

24-Hour Cancellation Policy: We require at least 24 hours' advance notice for any appointment cancellation or rescheduling.

Late Cancellation Fee: Appointments cancelled with less than 24 hours' notice will be subject to a $30.00 late cancellation fee. This fee is not covered by insurance and is the patient's responsibility.

No-Show Fee: Patients who fail to arrive for a scheduled appointment without prior notification will be charged a $50.00 no-show fee. This fee is not covered by insurance and is the patient's responsibility.

Repeated No-Shows: Patients with three (3) or more no-show occurrences within a 12-month period may be subject to dismissal from the practice at the discretion of the provider.

We understand that emergencies happen. Please contact our office as soon as possible at (813) 419-3108.

I authorize Breathewell Pulmonary Clinic to securely keep my credit or debit card information on file for the purpose of collecting patient responsibility balances, including:

• Copayments, coinsurance, and deductible amounts as determined by my insurance plan
• Balances remaining after insurance processing
• Late cancellation and no-show fees as outlined in the Cancellation Policy
• Any outstanding balance not paid within 60 days of the date of service

I understand that Breathewell Pulmonary Clinic will make a good-faith effort to notify me of any charges before processing, and that I will receive an itemized statement for all charges. My card information will be stored securely in compliance with PCI-DSS standards and will not be shared with unauthorized parties. I may revoke this authorization at any time by providing written notice.

Credit card information will be collected securely by our office staff at your first visit or via our secure patient portal.