FEE INFORMATION CONFIDENTIALITY STATEMENT

The enclosed fee schedule is provided out of courtesy and for your internal information only. It is not intended to be used to establish or revise any current fees of your practice. The Physician or Physician’s group, as-well-as any employees, affiliates, or agents, receiving this fee information may not, directly or indirectly, share or provide this information to any other venture, entity, or person not a part of Physician’s current practice. The acceptance of Physician or Physician’s group is evidenced to the right: