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Enrollment Package

Advantages to Using Emdeon Statement Services

Summary of Services Emdeon Expressbill Services: Emdeon Express Bill Services is an electronic statement processing service that is integrated with Compulink software.

Emdeon is an extension of your accounts receivable to improve collections, reduce costs to your office by saving time and money streamlining the billing process through electronic means.

Prompt, efficient delivery and accurate, easy-to-understand paper statements can result in faster patient payments. Emdeon ExpressBill Services taps the power of your billing database to create and deliver personalized patient statements.

Emdeon ExpressBill Services is your one-stop source for fast, effective statement processing, printing and mailing. Our statements and invoices can help cut your processing costs by shortening the time it takes to get statements from you to your patients. We provide the advanced bill printing that allows you to bypass conventional, time-consuming folding, stuffing and stamping of statements. We can also help you transmit billing information electronically to one of our process, print and mail centers.

Ease your returned mail burden with Emdeon ExpressBill Services, undeliverable mail is reduced by utilizing Emdeon Address Cleansing Services featuring USPS® NCOALink® technology. Emdeon ExpressBill Services also provides efficient processing, printing and mailing of clear, concise financial statements including postal pre-sorting and USPS® delivery.

Statement Pricing $.693 per statement, this covers processing the data, materials and first class postage. Each additional page is $.192 Prices could increase with any postage or paper increases.

NCOA Link Service - $.45 per address that is changed. Keep in mind a 100 record minimum is required for this service.

Enrollment Instructions

1. Complete the Request for Services enrollment form2. Complete the Business Associate Agreement3. Complete the NCOA Link Processing Acknowledgement Form4. Complete the Postage Deposit/Credit Forms for whichever services you will be utilizing. A one-time

fully refundable deposit is required before you can send live statements to Expressbill. Be sure to mail in your check to:

Emdeon Business Services 100 N. Byrne Rd Toledo, Ohio 43607

Once the forms are complete, click the send button (found on the last page) to return your enrollment forms to your Implementation Coordinator. Upon receipt of your forms, your enrollment will be forwarded to ExpressBill for processing. Within two weeks we will receive

an account number for your office, and will contact you to complete the setup process. Compulink will help you with the batching of the file so you can send it over to ExpressBill for processing.

Files received from the customer will be deemed as ‘test data’ until samples are presented to and approved by the customer. This approval converts the account to ‘live’ status pending the receipt of the postage deposit.

Please contact Compulink at 1-800-888-8075 with any questions about these forms or the process.

The Emdeon Advantage Printed Statements that are clear, concise and easily understood to help prompt faster

payments and reduce costs Sent through a high volume processing center in Toledo Ohio Prints and mails over 50,000,000 mail pieces per month Prompt and efficient next business day mail delivery No minimum volume requirements or contracts Send your files 24 hours/day – 7 days a week via Modem or High Speed Internet

Improved Cash Flow and Cost Savings Statements are printed and mailed with just a few clicks of a button Statements can have full color credit card logos that are easily recognized for payment

options Post net bar-coding speeds delivery of statements going out and payments coming back

to your office No form or envelope inventory to maintain Reduce cost on print cartridges and other mailing equipment/supplies Reduce labor cost on printing, folding, stuffing and stamping statements

Improved Customer Satisfaction Statements mailed in a timely manner, no need to wait for the end of the month Return envelope included with each statement Statements are easy to read which will help reduce calls coming back to office Add your office logo at no additional cost Confirmations are sent back to office so you can be assured your statements are mailed

Know when your statements are mailed You’ll receive file receipt confirmation to let you know we got your file You’ll receive a print confirmation which lets you know how many statements we

processed You may receive a bad address confirmation which shows any statements that were not

mailed due to a bad or incomplete addresses You may also receive a NCOA Link confirmation (if you sign up for the service). This will

report back to you the addresses that have been updated so be sure to update yourdatabase!

Patient Recalls Keep track of your patients and encourage them to return for follow up visits with patient recalls. Done using postcards or letters, your office can easily remind staff about return visits, needed follow-up, or provide information on why it is vital that they return to maintain good health.

The cost for sending out recalls is as follows: $.50 per postcard $.683 per recall letter, (each additional page is $.192)

This pricing covers processing the data, materials and first class postage. Prices could increase with any postage or paper increases.

If you are interested in sending recalls, please let your Compulink Implementation Coordinator know so that they can assist you with this.

Emdeon Patient Communications Extend the versatility of your software database and encourage patient participation and response with customized communication pieces offered through the Emdeon Patient Communications service. You’ll improve and enhance current patient relationships and invite new ones – economically and efficiently – with in-house design and print-and-mail service.

Keep patients up-to-date with your office, statement or practice changes and new features and benefits. Emdeon Patient Communications offers you complete database or select billing statement mailings, in-office handouts and other cost-effective communications that give you the professional edge. Create special mailings from your client database or your third-party source. Inform. Educate. Advance goodwill with your patients with helpful, timely communications.

Emdeon Document Archive Streamline your patient response time and save space when working to resolve patients’ financial inquiries, being able to quickly locate and view the exact document is crucial to providing good service. Emdeon Document Archive lets staff easily view statements and documents online 24/7 to streamline your patient response time. You’ll resolve patient issues quickly with Emdeon Document Archive’s fast access to high quality, full-color screen statements and documents. Instantly retrieve patient statements from your online browser. Emdeon Document Archive features online document access service with full name, account number and date range search capabilities for patient documents. After you forward your billing files, we’ll print and mail your statements, and with Emdeon Document Archive, maintain your documents for two months or longer for your convenience. For longer term storage needs, you can choose to have PDFs of your documents sent directly to you for retrieval and storage on internal systems.

REQUEST FOR SERVICES Patient Billing & Payment Solutions — Client Enrollment Form

FOR SALES USE ONLY Documents Signed: Date Received:

Postage Deposit Contract Business Associate Agreement

Please fill out the information COMPLETELY and email it to the location listed below: Emdeon

Email: ChannelPartnerSalesE@emdeon.com

Phone: 419-324-3091

General Information New Client Existing Client If Existing Client, list existing Accounts (Number, Name):

Format Requested to Match Existing Account (Number, Name):

City: State: Zip:

Business Type: Hospital Physician Office Dental Commercial Collections

Client Demographic & Systems Information Business Name:

Street Address:

Business Phone:

Contact Name: In-House Tech Contact: Ext#:

Fax Number:

(1) Email Confirmations To:

(2) Email Confirmations To:

Are you Tax Exempt? Yes No If Yes, please include your tax exemption form with enrollment

Financial InformationTax ID #:

Communication Information

Send Files by: BBS FTP Secure FTP/HTTP(if unsure check w/ your software vendor)

Set-Up By: Emdeon Business Services Software Vendor

Software:

Software Vendor/Channel Partner Information Software Vendor / Channel Partner: Compulink Contact Name:

Vendor Phone: Ext#: Email:

Product Selection Desired Live Date:

Emdeon ExpressBill Services (Print/Mail)

NCOALink: Yes No

Foreign/Canadian Mail: Yes No

Emdeon Document Archive (Extra Charge will apply)

Emdeon Patient Communications (Inserts) (Extra Charge will apply)

I would like an explanation brochure inserted with my new statements: Yes (Extra Charge will apply) No

Layout & Processing Information Product Type: Statements Letters Invoices Postcards Catalog#

Estim. Monthly Volume: (Please list volume for each product (ex: 100 statements/20 postcards)

Paper Information

Papertype: Standard Custom NOTE: A volume of 7,000 statements per month is required for custom paper

If Custom, is a Sample Form Provided: Yes No

Logo: Yes (must submit camera ready) No If Yes, Logo Format: JPG EPS TIF (High Resolution)

Credit Cards Accepted: MASTERCARD VISA DISCOVER AMEX Other: None

Duplexing: Yes (Extra Charge will apply) No Form Backprinting: Standard Custom (Enclose Sample) None

Include Payment Due by Date: Yes No If Yes, indicate number of days past statement date: days

For Office Use Only

PAPERTYPE: PASSWORD: Retail Wholesale Commercial REGION:

ACCOUNT NUMBER TYPE: 5 DIGIT BACKLINK

USERNAME:

rev 05/2012

Compulink Advantage

800-888-8075

Ext#:

BUSINESS ASSOCIATE AGREEMENT “Customer” or “Covered Entity”: “Business Associate”:

Each of the subsidiaries of Emdeon Business Services LLC, a Delaware limited liability company, listed on Exhibit A hereto as amended from time to time as provided herein, who has a relationship with Customer in which such entity creates or receives Protected Health Information (as defined below) for use in providing services or products to Customer.

Address: Medifax-EDI, LLC, an Emdeon company 3055 Lebanon Pike Nashville, TN 37214

Attention: Legal Department

Name of Entity:

Address:

City: ST: Zip:

Fax Number:

Attention: HIPAA PRIVACY OFFICER

Tax Identification Number:

RECITALS

WHEREAS, Business Associate now and in the future may have relationships with Customer in which Business Associate creates or receives Protected Health Information (as defined below) for use in providing services or products to Customer.

WHEREAS, Business Associate and Customer (each a “Party” and collectively the “Parties”) desire to meet their obligations, to the extent applicable, under the Standards for Privacy of Individually Identifiable Health Information (the “Privacy Regulation”) and the Health Insurance Reform: Security Standards (the “Security Regulation”) published by the U.S. Department of Health and Human Services (“HHS”) at 45 C.F.R. parts 160 and 164 under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), and as may be applicable to the services rendered by Business Associate to the Customer, under the Gramm-Leach-Bliley Act ("GLB") and implementing regulations.

WHEREAS, the Parties desire to set forth the terms and conditions pursuant to which Protected Health Information that is provided by, or created or received by, the Business Associate on behalf of the Customer (“Protected Health Information”), will be handled between themselves and third parties.

NOW THEREFORE, in consideration of the foregoing and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Parties hereby agree as follows:

TERMS AND CONDITIONS

1. PERMITTED USES AND DISCLOSURES OF PROTECTEDHEALTH INFORMATION

1.1 Services. (a) Business Associate provides services (which may include transaction services as well as servicing hardware or software products) (“Services”) that involve the use and/or disclosure of Protected Health Information. These Services are provided to Customer under various agreements ("Service Agreements") that specify the Services to be provided by Business Associate. Except as otherwise specified herein, the Business Associate may make any and all uses and disclosures of Protected Health Information created or received from or on behalf of Customer necessary to perform its obligations under the Service Agreements.

(b) Business Associate may perform Data Aggregation for the Health Care Operations of Customer.

1.2. Public Health Activities. Business Associate may use, analyze, and disclose the Protected Health Information in its possession for the public health activities and purposes set forth at 45 C.F.R. § 164.512(b)

1.3. Business Activities of the Business Associate. Unless otherwise limited herein, the Business Associate may: (a) consistent with 45 C.F.R. § 164.504(e)(4), use and disclose the Protected Health Information in its possession for its proper management and administration and to fulfill any present or future legal responsibilities of the Business Associate; and

(b) de-identify any and all Protected Health Information in accordance with 45 C.F.R. § 164.514(b). Customer acknowledges and agrees that de-identified information is not Protected Health Information and that Business Associate may use such de-identified information for any lawful purpose.

2. RESPONSIBILITIES OF THE PARTIES WITH RESPECT TOPROTECTED HEALTH INFORMATION

2.1. Responsibilities of the Business Associate. Business Associate agrees to: (a) use and/or disclose the Protected Health Information only as permitted or required by this Agreement or as otherwise required by law. Without limiting the foregoing, Business Associate will not sell Protected Health Information or use or disclose Protected Health Information for purposes of marketing, as defined and prescribed in the Privacy Regulation and the American Recovery and Reinvestment Act of 2009 (“ARRA”);;

(b) report to the Customer any use and/or disclosure of the Protected Health Information of which Business Associate becomes aware that is not permitted or required by this Agreement, including but not limited to any breach of unsecured Protected Health Information in compliance with any reporting requirements applicable to Business Associate under regulations implementing ARRA;

(c) report to Customer any Security Incident of which it becomes aware with respect to Electronic Protected Health Information provided by, or created or received by, Business Associate on behalf of Customer (“Electronic Protected Health Information”);

(d) mitigate, to the extent practicable, any harmful effect that is known to Business Associate of a use or disclosure of Protected Health Information by Business Associate not provided for by this Agreement;

(e) use appropriate safeguards to prevent use or disclosure of Protected Health Information other than as permitted or required by this Agreement;

(f) (i) implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the Electronic Protected Health Information that it creates, receives, maintains, or transmits on behalf of Customer; and (ii) make its policies and procedures, and documentation required by the Security Regulation relating to such safeguards, available to the Secretary of HHS for purposes of determining Customer’s compliance with the Security Regulation;

(g) require all of its subcontractors and agents that receive, use or have access to Protected Health Information, to agree to adhere to the same restrictions and conditions on the use and/or disclosure of Protected Health Information that apply to the Business Associate;

(h) ensure that all of its subcontractors and agents to whom it provides Electronic Protected Health Information agree to implement reasonable and appropriate safeguards to protect such Electronic Protected Health Information;

EBS Business Associate Agreement ARRA.0210 Page 1

(i) make available its internal practices, books and records relating to the use and/or disclosure of Protected Health Information to the Secretary of HHS for purposes of determining the Customer’s compliance with the Privacy Regulation;

(j) (i) record all disclosures by Business Associate of Protected Health Information required to be recorded by 45 CFR § 164.528 and, effective upon the compliance date applicable to Customer, by regulations promulgated by HHS pursuant to ARRA, and (ii) within thirty (30) days of receiving a written request from Customer, make available such information to the extent necessary for Customer to make an accounting of disclosures of an individual's Protected Health Information;

(k) within fifteen (15) days of receiving a written request from Customer, make available Protected Health Information necessary for Customer to respond to individuals’ requests for access to Protected Health Information about them, to the extent that the Protected Health Information in Business Associate’s possession constitutes a Designated Record Set;

(l) within thirty (30) days of receiving a written request from Customer, incorporate any amendments or corrections to the Protected Health Information in accordance with the Privacy Regulation, to the extent that the Protected Health Information in Business Associate’s possession constitutes a Designated Record Set; and

(m) limits its uses and disclosures of, and requests for, Protected Health Information (i) when practical, to the information making up a Limited Data Set when practical, and (ii) in all other cases subject to the requirements of 45 CFR § 164.502(b), to the minimum amount of Protected Health Information necessary to accomplish the intended purpose of the use, disclosure or request.

2.2. Responsibilities of the Customer. (a) With regard to the use and/or disclosure of Protected Health Information by the Business Associate, the Customer agrees: (i) to obtain any consent, authorization or permission that may be required by the Privacy Regulation or any other applicable federal, state or local laws and/or regulations prior to furnishing Business Associate the Protected Health Information pertaining to an individual; and (ii) that it will not furnish Business Associate Protected Health Information that is subject to any arrangements permitted or required of the Covered Entity, including but not limited to, arrangements agreed to by Customer under 45 C.F.R. § 164.522 that may impact in any manner the use and/or disclosure of Protected Health Information by the Business Associate under this Agreement and the Service Agreement(s).

(b) Customer represents and warrants that its notice of privacy practices permits Customer to use and disclose Protected Health Information in the manner that Business Associate is authorized to use and disclose Protected Health Information under this Agreement.

3. TERM AND TERMINATION

3.1. Term. Each term and condition of this Agreement shall become effective on the Effective Date, unless such term or condition relates to Electronic Protected Health Information only, in which event such term or condition shall become effective on the later of (a) the compliance date applicable to the Customer under the Security Regulation or (b) the date on which the Parties have executed the Agreement. This Agreement shall continue in effect unless terminated as provided in this Section 3, provided, that certain provisions and requirements of this Agreement shall survive the expiration or termination of this Agreement in accordance with Section 4.4 herein.

3.2. Termination by the Customer. As provided for under 45 C.F.R. § 164.504(e)(2)(iii), the Covered Entity may immediately terminate this Agreement with respect to a Business Associate and any related Service Agreement(s) if the Covered Entity makes the determination that such Business Associate has breached a material term of this Agreement. Alternatively, Covered Entity may choose to provide such Business Associate written notice of the breach in sufficient detail to enable Business Associate to understand the specific nature of the breach and afford Business Associate an opportunity to cure the breach; provided,

however, that if such Business Associate fails to cure the breach within a reasonable time specified by Covered Entity, Covered Entity may terminate this Agreement with respect to such Business Associate and any related Service Agreement(s) to the extent that the Service Agreement(s) requires such Business Associate to create or receive Protected Health Information. If termination is not feasible, Customer shall report the breach to HHS.

3.3. Termination by Business Associate. Any Business Associate may immediately terminate this Agreement with respect to such Business Associate and any related Service Agreement(s) if such Business Associate makes the determination that Covered Entity has breached a material term of this Agreement. Alternatively, such Business Associate may choose to provide Covered Entity written notice of the breach in sufficient detail to enable Covered Entity to understand the specific nature of the breach and afford Covered Entity an opportunity to cure the breach; provided, however, that if Covered Entity fails to cure the breach within a reasonable time specified by Business Associate, Business Associate may terminate this Agreement as it relates to such Business Associate and any related Service Agreement(s) to the extent that the Service Agreement(s) requires such Business Associate to create or receive Protected Health Information. If termination is not feasible, Customer shall report the breach to HHS consistent with 45 CFR § 164.504(e)(1)(ii) and ARRA.

3.4. Automatic Termination. This Agreement will automatically terminate with respect to any Business Associate without any further action of the Parties upon the termination or expiration of all Service Agreement(s) between Customer and such Business Associate.

3.5. Effect of Termination. Upon the termination of this Agreement with respect to any one or more Business Associates, such Business Associate(s) agrees to return or destroy all Protected Health Information, including such information in possession of such Business Associate's subcontractors, if it is feasible to do so. If return or destruction of said Protected Health Information is not feasible, such Business Associate(s) will extend any and all protections, limitations and restrictions contained in this Agreement to the Business Associate’s use and/or disclosure of any Protected Health Information retained after the termination of this Agreement, and limit any further uses and/or disclosures to the purposes that make the return or destruction of the Protected Health Information infeasible.

4. MISCELLANEOUS

4.1. Entire Agreement. This Agreement, and all attachments, schedules and exhibits hereto, constitutes the entire agreement and understanding between the Parties with respect to the subject matter hereof and supersedes any prior or contemporaneous written or oral memoranda, negotiations, arrangements, contracts or understandings of any nature or kind between the Parties with respect to the subject matter hereof.

4.2. Change of Law. Customer shall notify Business Associate within ninety (90) days of any amendment to any provision of HIPAA, its implementing regulations set forth at 45 C.F.R. parts 160 through 164, or other applicable law which materially alters either Party’s or the Parties’ obligations under this Agreement. The Parties agree to negotiate in good faith mutually acceptable and appropriate amendment(s) to this Agreement to give effect to such revised obligations; provided, however, that if the Parties are unable to agree on mutually acceptable amendment(s) within ninety (90) days of the relevant change of law, either Party may terminate this Agreement consistent with sections 3.5 and 4.4.

4.3. Construction of Terms. The terms of this Agreement shall be construed in light of any interpretation and/or guidance on HIPAA, the Privacy Regulation and/or the Security Regulation issued by HHS from time to time.

4.4. Survival. Sections 3.5, 4.3, 4.8, 4.11, 5, 6 and this Section 4.4, and any other provisions of this Agreement that by their terms are intended to survive, shall survive the termination of this Agreement.

EBS Business Associate Agreement ARRA.0210 Page 2

4.5. Amendment; Waiver. This Agreement may not be modified, nor shall any provision hereof be waived or amended, except in a writing duly signed by authorized representatives of the Parties. A waiver with respect to one event shall not be construed as continuing, or as a bar to or waiver of any right or remedy as to subsequent events.

4.6. Notices. Any notices to be given hereunder to a Party shall be made via U.S. Mail or express courier to such Party’s address given above. Each Party may change its address and that of its representative for notice by the giving of notice thereof in the manner herein above provided.

4.7. Counterparts; Facsimiles. This Agreement may be executed in any number of counterparts, each of which shall be deemed an original. Facsimile copies hereof shall be deemed to be originals.

4.8. Disputes. If any controversy, dispute or claim arises between the Parties with respect to this Agreement, the Parties shall make good faith efforts to resolve such matters informally.

4.9 Effective Date. The Effective Date of this Agreement shall be the date on which the Parties have executed the Agreement.

4.10 Binding Agreement; New Parties; Agency.

(a) This Agreement shall be binding upon the Parties and their successors and permitted assigns. Any one or more additional subsidiaries of Emdeon Business Services LLC with a relationship with Customer in which such entity creates or receives Protected Health Information for use in providing services or products to Customer (each a “New Party”) may join this Agreement as a Party and a Business Associate by executing and delivering a counterpart of this Agreement. In addition, Emdeon Business Services LLC from time to time lists on its corporate website its subsidiaries which are business associates for purposes of HIPAA compliance (“HIPAA BA Subs”). Each HIPAA BA Sub that creates or receives Protected Health Information for use in providing services or products to Customer shall be deemed to be a New Party without further action by any Party hereto. Whenever a New Party joins this Agreement, Exhibit A will be deemed amended (and shall be revised at the request of any Party or Emdeon Business Services LLC as agent for the Business Associates) to list such New Party as a Business Associate hereunder.

(b) The Parties acknowledge that Emdeon Business Services LLC is executing and delivering this Agreement solely in its capacity as agent for the Business Associates. By signing below, Emdeon Business Services LLC represents that it has been authorized to execute this Agreement on behalf of each Business Associate, including any New Party who joins this Agreement under Section 4.10(a).

4.11 No Third Party Beneficiaries. Nothing in this Agreement shall confer upon any person other than the Parties and their respective successors or assigns, any rights, remedies, obligations, or liabilities whatsoever.

4.12 Contradictory Terms. This Agreement hereby amends, modifies, supplements and is made part of the Service Agreement(s), provided that any provision of the Service Agreement(s), including all exhibits or other attachments thereto and all documents incorporated therein by reference, that is directly contradictory to one or more terms of this Agreement (“Contradictory Term”) shall be superseded by the terms of this Agreement as of the date such terms become effective pursuant to Section 3.1, to the extent and only to the extent of the contradiction and only to the extent that it is reasonably impossible to comply with both the Contradictory Term and the terms of this Agreement.

5. LIMITATION OF LIABILITY

NEITHER PARTY SHALL BE LIABLE TO THE OTHER PARTY FOR ANY INCIDENTAL, CONSEQUENTIAL, SPECIAL, OR PUNITIVE DAMAGES OF ANY KIND OR NATURE, WHETHER SUCH LIABILITY IS ASSERTED ON THE BASIS OF CONTRACT, TORT (INCLUDING NEGLIGENCE OR STRICT LIABILITY), OR OTHERWISE, EVEN IF THE OTHER PARTY HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSS OR DAMAGES.

6. DEFINITIONS

Regulatory citations in this Agreement are to the United States Code of Federal Regulations Title 45 parts 160 through 164, as interpreted and amended from time to time by HHS, for so long as such regulations are in effect. Unless otherwise specified in this Agreement, all capitalized terms not otherwise defined shall have the meaning established for purposes of Title 45 parts 160 through 164 of the United States Code of Federal Regulations, as amended from time to time.

IN WITNESS WHEREOF, each of the undersigned has caused this Business Associate Agreement to be duly executed effective as of the Effective Date.

CUSTOMER EMDEON BUSINESS SERVICES LLC

By: By:

Print Name: Print Name:

Print Title: Print Title:

Date: Date:

EBS Business Associate Agreement ARRA.0210 Page 3

______________________________________ ______________________________________

Exhibit A

Advanced Business Fulfillment, LLC CareInsite LLC Claims Processing Service LLC Dakota Imaging LLC Dakota Imaging, S.A. (Sociedad Anonima) Emdeon Clinical Services, LLC Envoy LLC eRx Audit, LLC eRx Network, L.L.C. ExpressBill LLC Interactive Payer Network LLC (IPN) IXT Solutions, Inc. IXT Solutions Services, Inc. MedE America LLC MedE America of Ohio LLC Medi, Inc. Medifax-EDI, LLC

The Sentinel Group Services LLC

EBS Business Associate Agreement ARRA.0210 Page 4

Please fill out the information COMPLETELY and fax or mail it to the location listed below

Postage deposit & Credit information

On the web at: www.emdeon.com http://www.emdeon.com/Physicians/physicians_patientbilling.php

Emdeon Business Services – OH Attn: Renee Bacon 100 N. Byrne Road TOLEDO, OH 43607-0494 PHONE: 419-324-3075 FAX: 419-324-1418

Please keep a copy of this for your records

POSTAGE DEPOSIT

Emdeon maintains a strict policy of collecting a postage deposit from all customers utilizing our postcard mailing service. Your postage deposit is not deducted from the first month’s bill, it is held by Emdeon on your behalf. This deposit is based on an estimate of your postage usage during a 30-day period, according to the calculation below, or $50.00, whichever is greater.

Please make your postage deposit check payable to Emdeon. Upon termination or expiration of your use of Emdeon the postage deposit will be refunded less: (i) the cost of unused custom paper; and (ii) any outstanding payment due to Emdeon Business Services. The cost of unused custom paper will be determined at a cost of thirty-five dollars ($35) per thousand (1,000).

Postage Deposit Worksheet

.33

number of your monthly postcards x postage rate = postage deposit amount (or) minimum deposit of $50

(WHICHEVER IS GREATER)

Please Note: Emdeon will not be able to process a customer’s live data file until the postage deposit has been received. Make check payable to: Emdeon and enclose the check with the completed copy of this form to one of the following address: Emdeon, 100 N Byrne Rd, Toledo, OH 43607-0494 Attn: Renee’ Bacon

CLIENT INFORMATION

Facility Name (including d/b/a, a/k/a, f/k/a, etc.)

Street Address:

City: State: Zip:

Bill-to Address (if different from above):

Address:

City: State: Zip:

Accounts Payable Employee to Contact:

Phone / Ext: Website Address:

Direct Invoices to: Email Address:

P.O. # (if applicable): Tax ID:

ExpressBill Acct. # (if known): (TAX ID IS REQUIRED)

Sales Representative:

Authorized Signature & Title: Date:

© Emdeon Corporation 89-19-0403 (rev 04/11)

__________________________________________

Please fill out the information COMPLETELY and fax or mail it to the location listed below

Postage deposit & Credit information

On the web at: www.emdeon.com http://www.emdeon.com/Physicians/physicians_patientbilling.php

Emdeon Business Services – OH Attn: Renee’ Bacon 100 N. Byrne Road TOLEDO, OH 43607-0494 PHONE: 419-324-3075

FAX: 419-324-1418

Please keep a copy of this for your records

POSTAGE DEPOSIT

Emdeon maintains a strict policy of collecting a postage deposit from all customers utilizing our statement mailing service. Your postage deposit is not deducted from the first month’s bill, it is held by Emdeon on your behalf. This deposit is based on an estimate of your postage usage during a 30-day period, according to the calculation below, or $50.00, whichever is greater.

Please make your postage deposit check payable to Emdeon. Upon termination or expiration of your use of Emdeon the postage deposit will be refunded less: (i) the cost of unused custom paper; and (ii) any outstanding payment due to Emdeon Business Services. The cost of unused custom paper will be determined at a cost of thirty-five dollars ($35) per thousand (1,000).

Postage Deposit Worksheet

.385

number of your monthly statements x postage rate = postage deposit amount (or) minimum deposit of $50

(WHICHEVER IS GREATER)

Please Note: Emdeon will not be able to process a customer’s live data file until the postage deposit has been received. Make check payable to: Emdeon and enclose the check with the completed copy of this form to the following addresses; Emdeon, Attn; Renee Bacon, 100 N Byrne Rd, Toledo, OH 43607-0494 Attn: Renee’ Bacon

CLIENT INFORMATION

Facility Name (including d/b/a, a/k/a, f/k/a, etc.)

Street Address:

City: State: Zip:

Bill-to Address (if different from above):

Address:

City: State: Zip:

Accounts Payable Employee to Contact:

Phone / Ext: Website Address:

Direct Invoices to: Email Address:

P.O. # (if applicable): Tax ID:

ExpressBill Acct. # (if known): (TAX ID IS REQUIRED)

Sales Representative:

Authorized Signature & Title: Date:

© Emdeon Corporation 89-19-0403 (rev 04/11) ___________________________________________

Please return this page and the NCOALink™ PAF form to enroll in the NCOALink™ Service.

Re: NCOALink Service1

Dear Valued Client,Thank you for using Emdeon Business Services’ print and mail service. Are you aware that Emdeon Business Services can alsohelp reduce the amount of returned mail to your facility?

Emdeon Business Services uses NCOALink™ Service, licensed by the United States Postal Service®, to search all permanentchange of address records filed with the USPS® within the last 18 months. When a match is found, permanently changed addressesare corrected and mailed to the updated address. In addition, you will appreciate the COST SAVINGS – almost 1/2 half the cost ofthe USPS® fee (currently $0.75 and subject to change without notice)!

So to recap. . . By enrolling in the NCOALink™ Service your facility will:• Speed delivery of your mail by having the correct address on the first mailing.• Promote faster payments.• Reduce your address correction cost.• Receive updated address information for your records.• Make you aware when clients have moved and left no forwarding address. This could alert collection proceedings.

Now. . . How Do I get this service? It’s easy --1. Select a Postal endorsement that will appear on your statements (check box). This will determine how the USPS®

will handle your mail IF there is no change available in the NCOALink™ Service and the mail is undeliverable. Youmust select ONE of them. Following is a description of each of the postal endorsements and the process associatedwith each.

Address Service Requested- For the first 12 months that the address has changed, The USPS® will send you a post card with the new

address on it and charge a fee payable by your office (currently $0.75 subject to change without notice).The mail will be forwarded to the address as supplied on the change of address card submitted by theUSPS®.

- After 1 year since the address change, the USPS® will return the mail piece to your facility with the reason,or address update. No fee will be charged for these returned mail pieces.

Return Service Requested- The USPS® returns any undeliverable mail with a new address or reason for non-delivery to you at no

charge.

Temp Return Service Requested- This covers the ‘Snow-Birds’ that have a temporary change on file at their local Post Office™. The mail is

re-directed to the address they provide with no notification to you. There is no fee associated with thisservice.

No Service requested- This will cause your statements to have no postal endorsement on them.- For the first 12 months that the address has changed, The USPS® will send to the new address with no

notification sent to your office. After 1 year since the address change, the USPS® will return the mail pieceto your facility with the reason, or address update. There is no fee associated with this service.

1 Emdeon Business Services is a non-exclusive Limited Service Provider Licensee of the United States Postal Service® NCOALink™ Service. The following trademarks areowned by the United States Postal Service: NCOALink, USPS®, Post Office and United States Postal Service®.

100 N. Byrne RoadToledo, OH 43607

Medical:

621111 Offices of Physicians(except Mental Health Specialists)

621210 Offices of Dentists

621320 Offices of Optometrists

621391 Offices of Podiatrists

621512 Diagnostic Imaging Centers

622110 General Medical and Surgical Hospitals

Commercial:

312112 Bottled Water Manufacturing

454312 Liquefied Petroleum Gas(Bottled Gas) Dealers

517110 Wired Telecommunications Carriers

524126 Direct Property and CasualtyInsurance Carriers

524292 Third Party Administration ofInsurance and Pension Funds

562212 Solid Waste Landfill

2. Complete the top Section only with all requested information and correct what may be in error. Please DO NOTcomplete the “Licensee” or “Broker Agent” sections of the form (these are for Emdeon use only).

3. Provide your companies NAICS ID code . This code is used to identify your type of business tothe USPS® and can be found at http://www.census.gov/epcd/naics02/naico602.htm. Per the USPS®, this code isMANDATORY. Therefore, we cannot enroll you in the NCOALink™ Service without it.

Common NCOALink™ NAICS ID codes:

4. Place this page and the NCOALink™ Processing Acknowledgement Form in the supplied envelope and mail.That’s it.2

* * There is a minimum file size required to qualify for address updates. Your files MUST contain 100 or more validunique addresses in order to qualify for address updates.

For additional information please contact the Emdeon Help Desk at (800) 537-7563 (option 5).

Thank you,

Emdeon Business Services, Customer Service Dept.

Attachment: NCOALink™ Processing Acknowledgement Form

2 Please note you cannot benefit from this service until Emdeon Business Services receives your completed NCOALink™ Service Processing Acknowledgement form.

(page 1 of 3)

Emdeon is a non-exclusive Licensee of the USPS® (United States Postal Service®) to provide Limited Service NCOALink

processing.

It is important to note that not all Service Providers can offer the same level of service. Data quantity differs based on licenselevel. Full Service Providers receive the full 48 month data set while Limited Service Providers receive an 18 month data set.All data fulfillments to Service Providers are provided weekly under direct license from the USPS.

The full NCOALink file is a consolidated file of move information that on average contains approximately 160 million permanentchanges-of-address (COAs) filed with the United States Postal Service (USPS). These COAs are retained on the file for a four-year period from the move-effective date and the file is updated weekly.

Before being added to the NCOALink file, the Old address supplied by the Postal customer must be ZIP + 4 coded. The Newaddresses must be ZIP + 4 coded and validated using the USPS’ proprietary database of actual delivery points. (NOTE: Thedelivery point database does not include NAMES or COA information.) Each delivery point confirmed New address is includedon the NCOALink file. If unable to validate the New address, the NCOALink process will indicate that a move exists but willnot provide the undeliverable New address.

New address information is provided only when a match to the input name and address is attained. The typical profile of theNew address information contained on the NCOALink file is as follows:

80.92% Forwardable moves containing delivery point confirmed New addresses –New address provided

1.18% Moves containing unconfirmed New addresses – New address not provided13.80% Moved, left no address

3.92% PO Box Closed0.18% Foreign moves

When possible, postal customers who move multiple times within the NCOALink time period are “linked” or “chained” toensure that the latest address is furnished when an NCOALink match is attained. This is not always possible if subsequent COAsare not filed in exactly the same manner as a COA filed previously (e.g., name spelling differences or conflicting secondaryinformation).

The provision of change of address information is controlled by strict name and address matching logic. NCOALink processingwill only provide new address information when queried with a specific algorithm of the name and input address from a mailersaddress list which matches the information on the NCOALink Product. Data contained in and information returned by NCOALink

is determined by the name and move type (Business, Individual, or Family) indicated on a Postal customer’s Change of Addressform.

NCOALinkTM LIMITED SERVICE PROVIDERREQUIRED TEXT DOCUMENT

AD#2.06

(page 2 of 3)

The data contained within the NCOALink Product is comprised of approximately 40% family moves, 54% individual moves,and 6% business moves.

All matches made to the NCOALink file require a ZIP + 4 coded, parsed input address.

The five types of processing modes are Standard (S); Business and Individual (C); Individual (I); Business (B); and Residential(R).

Standard Processing Mode (S)• Standard Processing Mode requires inquiries in the following order:• Business – Match on business name.• Individual – Match on first name, middle name, surname and title required. Gender is checked and nickname possibilities

are considered.• Family – Match on surname only.• Under no circumstances shall there be a “Family” match only option.

Business and Individual Processing Mode (C)• The NCOALink customer may choose to omit all “Family” match inquiries and allow only “Individual” and “Business”

matches to be acceptable. This matching process is also known as C Processing Mode.

Individual Processing Mode (I)• The NCOALink customer may also choose to omit “Business” match inquiries when processing individual names for

mailing lists that contain no business addresses.

Business Processing Mode (B)• The NCOALink customer may choose to process for only “Business” matches when processing a “Business-to-Business”

mailing list which contains no residential (Individual or Family) addresses.

Residential Processing Mode (R)• The NCOALink customer may choose to omit “Business” match inquiries and allow only “Individual” and “Family”

matches to be acceptable under Residential Processing Mode. This matching process is also known as R ProcessingMode.

The USPS has opted to remove soundex from the matching logic process. Consequently, the USPS has established a processcalled the “Rules Table.” This process will produce matches that otherwise would not be possible, i.e. JOHNY and JOHNNY,without the risks associated with soundex.

All nickname possibilities are derived from a standard USPS nickname list. In considering alternate presentations of an inputname, only reasonable derivatives of the original input name are acceptable. If an input name and address do not match toNCOALink and alternative queries are attempted, any variations which obtain NCOALink matches will be provided to theNCOALink customer for analysis.

NCOALinkTM LIMITED SERVICE PROVIDERREQUIRED TEXT DOCUMENT

AD#2.06

NCOALinkTM LIMITED SERVICE PROVIDERREQUIRED TEXT DOCUMENT

(page 3 of 3)

When a match or a near match of an input name and address to NCOALink is identified, a standard NCOALink return code isprovided indicating the type of match made or reason that a match could not be made.

The standard output of a USPS NCOALink process is:

a) Each original unaltered input name and address as it was presented.b) The standardized input address appended with the correct ZIP + 4/DPC, other postal values and any other intelligence

flags or footnotes that result from the CASS™ processing segment.c) For each mailing address for which there is a match to the NCOALink Product, a standardized new address with 11-

digit Delivery Point Barcode (DPBC) and standard return codes.d) When a match is made, the following elements must be returned: the move effective date, the specific name and

address utilized in the query that obtained the match, and the move type. The move type is determined by the Interfacebased on the specific name inquiry utilized to obtain the match.

e) For each mailing address for which there is not a match to the NCOALink Product, the Interface shall return all elementsas appropriate under items a and b as well as any standard return codes as may be appropriate.

f) The urbanization name information, when applicable.g) The carrier route information for new (updated) addresses.h) Processing summary report containing information to identify the specific list and the statistics resulting from the

NCOALink process performed on the list.

Although every record must be returned, the format of the records returned by a Service Provider to their clients is determinedby a separate agreement between the processor and the customer.

NCOALink processing has the potential to reduce returned mail, yet the USPS does not make any guarantees, express orimplied, on the reduction of such mail. Thus any costs associated with returned mail are the Licensees’ and/or their customers’sole responsibility.

An NCOALink customer with questions about the specific results returned from an NCOALink process must first contact theprocessor for explanation and resolution.

Prior to the processing of NCOALink data, every customer must have completed and returned to their NCOALink Licenseethe “NCOALink PROCESSING ACKNOWLEDGEMENT FORM” provided to them by their Licensee or Agent. It is inappropriateto misrepresent any of the information on the form. Punitive action will be taken by the USPS if the customer, agent or licenseeis found to have knowingly supplied false information. Depending on the severity of the offense, actions may include litigiousor even criminal charges being brought against the offender.

The following trademarks are owned by the United States Postal Service®: CASS, NCOALink, United States Postal Service,USPS and ZIP + 4.

AD#2.06

NCOALink

™ PROCESSING ACKNOWLEDGEMENT FORM The collection of information on this Processing Acknowledgement Form (PAF) is required by the Privacy Act of 1974. The United States Postal Service (USPS) requires that each NCOA

Link Licensee have a completed NCOA

Link PAF for each of their NCOA

Link customers prior to providing the NCOA

Link service.

The Licensee is also required by the USPS to retain a copy of the completed form for each of its customers and to obtain an updated PAF from each of its customers at minimum once per year. Any signature upon this PAF shall be considered valid for all purposes and have the same effect whether it is an ink-signed original or a photocopy or facsimile representation of the original document.

LIST OWNER

I, the undersigned, an authorized representative of:

Company Name

Address

- City State ZIP+4

Telephone Number Postal ID (for future use) Tax Identification Number (TIN) NAICS

Parent Company Name

Marketing or “DBA” Company Name or Primary Affiliate Company Name

Name (Please print) Title

Signature Date

do hereby acknowledge that I have received and reviewed the NCOALink

Information Package supplied to me by Emdeon ,an NCOA

Link Limited Service Provider Licensee. I also understand that the sole purpose of the NCOA

Link service is to provide a mailing list

correction service for lists that will be used for preparation of mailings. Furthermore, I understand that NCOALink

may not be used to createor maintain new movers lists.

LICENSEE

Emdeon Business Name (Please print)

Customer Service DepartmentName (Please print) Title

Signature Date

(800) 537-7563 (option 5) 62-1729667Telephone Number Tax Identification Number (TIN)

BROKER/AGENT LIST ADMINISTRATOR (Check applicable box)

Business Name (Please print)

- Address City/State/ZIP+4

Name (Please print) Title

Signature Date

Telephone Number Tax Identification Number (TIN) NAICS

For Licensee Use Only

PAF ID: Broker/Agent ID: List Administrator ID:

STATEMENT DATE PAY THIS AMOUNT ACCT. #

SHOW AMOUNT

PAID HERE $

CHECK CARD USING FOR PAYMENT

MASTERCARD VISA AMERICAN EXPRESS

IF PAYING BY MASTERCARD, DISCOVER, VISA OR AMERICAN EXPRESS, FILL OUT BELOW.

DISCOVER

500005A (PC1)

CARD NUMBER SIGNATURE CODE

SIGNATURE EXP. DATE

IF ANY OF THE FOLLOWING HAS CHANGED SINCE YOUR LAST STATEMENT, PLEASE INDICATE . . . .

ABOUT YOU: ABOUT YOUR INSURANCE:YOUR NAME (Last, First, Middle Initial)

ADDRESS

CITY STATE ZIP

TELEPHONE MARITAL STATUS

( )

EMPLOYER’S NAME TELEPHONE

( )

EMPLOYER’S ADDRESS CITY STATE ZIP

YOUR PRIMARY INSURANCE COMPANY’S NAME EFFECTIVE DATE

PRIMARY INSURANCE COMPANY’S ADDRESS PHONE

CITY STATE ZIP

POLICYHOLDER’S ID NUMBER GROUP PLAN NUMBER

YOUR SECONDARY INSURANCE COMPANY’S NAME EFFECTIVE DATE

SECONDARY INSURANCE COMPANY’S ADDRESS PHONE

CITY STATE ZIP

POLICYHOLDER’S ID NUMBER GROUP PLAN NUMBER

SingleMarried

SeparatedDivorcedWidowed

( )

( )

Patient Statement Enrollment Checklist

Request for Services -Please make sure this form is completed to its entirety. If any of the following items are missing the enrollment CANNOT be processed so please make sure this information is filled in: 1) Tax ID2) Estimated Monthly Volume (If a client is signing up for statements and postcards at the same time,there should be a separate volume number listed for each line of business) 3) Credit Cards Accepted

Business Associate Agreement -Please make sure the first page is completed and the 3rd page is completed and signed

Postage Deposit Form -This form along with an explanation of its necessity should be presented to every new customer. -If a customer is signing up for BOTH statements and postcards at the same time, they will need to pay a deposit for each line of business. Statement deposits are calculated using the $.385 postage rate and postcard deposits are calculated using the $.33 postage rate. -If the customer is only signing up for/implementing statements, then the $.385 postage form is the only one that needs completed. -Please keep in mind that the check for the postage deposit(s) must be received during implementation and before we start processing live statement or postcard files.

NCOAlink Forms -Please make sure that all forms are completed. This includes: 1) The first page, which is requesting what type of postal endorsement the customer chooses (AddressService Requested, Return Service Requested, etc.) Please only choose ONE 2) The second page, which asks the customer to list their NAICS ID Code (621111 Offices of Physicians,621320 Offices of Optometrists, etc.) 3) And the last (5th) page which is the “Processing and Acknowledgement” page (The first box is the onlyone that needs completed)

Customer LOGO (If applicable) -An electronic version is the only acceptable version -It can be emailed to ChannelPartnerSalesE@emdeon.com along with the enrollment forms