PRACTICE INFORMATION & PATIENT/PHYSICIAN CONTRACT

Please correct the errors described below.

Dear Patient, Welcome to our practice specializing in gastroenterology and hepatology. At the present time, our group consists of Patrick G. Tempera, M.D., Rajesh Dhirmalani, D.O., and Kunal Grover, M.D., Michael J. Viksjo, M.D., Prakriti S. Merchant, M.D., Arun R. Mathew, M.D. all Board Certified physicians in Internal Medicine and Gastroenterology, along with Guida St. George, MS, PA-C, and Tracey Alves, APN-C. Office hours will vary each day of the week and there may be variations in-office hours during different seasons, so please inquire at our front desks for our current office hours. Overall, however, staff is present in the office between 9 a. m. and 6 p. m. on weekdays. The office is closed on weekends. All our appointments are scheduled, but provisions are always made for emergency walk-ins as the case becomes necessary. The physicians in our practice are able to perform all the gastroenterological-based procedures and may see a given patient at different times depending on availability. Our practice is office based; however we will also care for all our patients in the hospital. If they are hospitalized, whether we initiate the hospitalization, or other physicians do so, and request that we also provide consultation care. The Garden State Endoscopy & Surgery Center is also a place of work for us, where many of our patients are evaluated and treated for their endoscopic procedures. Hospital coverage is provided by members of our group and other associated physicians in the covered hospitals; they are also Board Certified in digestive diseases. We are on staff at Trinitas Regional Medical Center in Elizabeth, New Jersey, Robert Wood Johnson at Rahway Hospital in Rahway, New Jersey and Overlook Hospital in Summit, New Jersey. We always prefer that test results/information about other diagnostic results be discussed by us and the patient in person at our office. It is a policy of our practice to fill prescriptions only during regular office hours. In the event that you must cancel an appointment, we ask that you please give us 48-hours notice so that we can give that appointment to another patient on our waiting list. Once you call to cancel, we can reschedule you at your convenience. There will be a $50 charge for missed appointments that are not cancelled at least 24-hours prior the appointed time. We take great pride in our reputation to provide the highest level of quality medical care to our patients. However, we realize that there are times that some patients will not be satisfied with the outcome of their treatment. We also recognize that in these instances, the patient has every right to pursue legal action if he or she feels that we have been negligent in some way. We respect every patient’s right to do so. While some health care legal claims are justified, there are also frivolous legal claims filed in our country – claims that are driving up insurance rates and impacting court decisions for the patients who truly deserve compensation. We believe that an agreement early in the treatment process regarding the use of Board Certified Experts will help expedite resolutions of concerns.

OUR COMMITMENT TO YOU

WE COMMIT TO USING ONLY AMERICAN BOARD OF MEDICAL SPECIALITIES (ABMS) BOARD CERTIFIED EXPERT MEDICAL WITNESSES IN ANY LEGAL SITUATION WHO FOLLOW THE CODE OF ETHICS OF OUR NATIONAL SPECIALTY SOCIETY. THESE STEPS ENSURE THAT EXPERT MEDICAL WITNESSES WE USE HAVE PASSED EXAMINATIONS AND DEMONSTRATE EXPERTISE IN THEIR FIELD AND ADHERE TO A SOLID CODE OF ETHICS AND WE WILL DEMONSTRATE THIS COMMITMENT TO YOU WITH OUR SIGNATURE ON THIS FORM. WHAT WE ARE ASKING YOU TO DO – WE ARE ASKING YOU OR ANY REPRESENTATIVE TO COMMIT TO THIS PROCESS ALSO BY USING ONLY BOARD CERTIFIED PHYSICIANS AND EXPERT MEDICAL WITNESSES IF YOU ARE DISSATISFIED WITH YOUR MEDICAL CARE AND DECIDE ON LEGAL ACTION. WE HOPE AND BELIEVE THAT YOU WILL NEVER HAVE TO CONSIDER THIS AGAIN, BUT IF YOU DO, WE WILL HONOR THIS COMMITMENT TO YOU.

PATIENT/PHYSICIAN AGREEMENT

I understand that I am entering into a contractual relationship with Ramon F. Ledon, M. D., Patrick G. Tempera, M.D., Rajesh Dhirmalani, D. O., Kunal Grover, M. D., Ellen C. Ebert, M.D., Michael J. Viksjo, M.D. and Guida St. George, MS, PA-C for professional care. I further understand that meritless and frivolous claims for medical malpractice have an adverse effect upon the cost and the validity of medical care and may result in irreparable harm to a medical provider. As additional consideration for professional care provided to me by Ramon F. Ledon, M.D., Patrick G. Tempera, M.D, Rajesh Dhirmalani, D.O., Kunal Grover, M.D., Ellen C. Ebert M.D., Michael J. Viksjo, M.D.and Guida St. George, MS, PA-C,

and/or my representative agree not to advance directly or indirectly any false meritless and/or frivolous claims of medical malpractice against Ramon F. Ledon, M. D., Patrick G. Tempera, M. D., Rajesh Dhirmalani, D. O., Kunal Grover, M. D., Ellen C. Ebert M.D., Michael J. Viksjo, M.D. and Guida St. George, MS, PA-C.

Furthermore, should a meritorious medical malpractice case or cause of action be initiated or pursued,

and/or my representative agree to use ABMS Board Certified Expert Medical Witnesses in the same specialty as Drs. Ramon F. Ledon, Patrick G. Tempera, Rajesh Dhirmalani, Kunal Grover, Ellen C. Ebert, Michael J. Viksjo and Guida St. George, MS, PA-C. Furthermore, I agree that these expert witnesses will adhere to the guidelines and/or code of conduct defined by the Specialty Societies for Expert Witnesses in the areas of medicine that would typically have the background and experienced to opine on such a case. In further consideration for this, we, Drs. Ramon F. Ledon, Patrick G. Tempera, Rajesh Dhirmalani, Kunal Grover, Ellen C. Ebert, Michael J. Viksjo and Guida St. George, MS, PA-C, agree to the same stipulations.

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