HILLTOP MEDICAL CLINIC
1093 Hilltop Drive, Redding, CA  96003

DEAR MEDICARE PATIENT,

1.  Hilltop Medical Clinic is a NON-Participating Provider for Medicare.  We have a provider  
     number with Medicare for them to process the claim directly to you.

2.  We are payment at the time of service.  We do NOT  Accept Assignment (Medicare
      payment) on Medicare claims.

3.  Medicare will consider reimbursement on the Physician, Xray and some injection charges. 
     We are notifying you that medicare will NOT reimburse you for the following services
     (nor will Hilltop Medical Clinic) and by signing this you understand you will owe for:

       A.  Laboratory tests performed in our office that get applied toward your deductible.
       B.  Handling charges on laboratory tests sent to an outside lab.
       C.  Various allergy or hormone injections or immunizations (tetanus).
       D.  General Physical exams and the corresponding tests, includeing TB tines or PPD tests.
       E.  All medical supplies (i.e. Orthopedic, suture tray, dressings, etc).
       F.  Oral prescription drugs purchased from our clinic.

4.  At this time, we are unaware of any other services we provide which are determined by  
     Medicare to be not covered because they are not reasonable and necessary for treatment of
     illness or injury.

5.  My signature below authorizes Hilltop Medical Clinic to release medical information about
     me to the C.M.S. formerly N.H.I.C. and its agents to determine these benefits payable
     to related services.  I understand my signature requests that payment be made to me and
     authorizes release of medical information necessary to process the claim.

6.  Please Note, as of 9/1/1990 - Hilltop Medical Clinic is required by law to submit your
     claims to medicare for N.H.I.C. and Medicare is to respond directly to you.  Please
     do not submit your own claims to Medicare.  Allow 30-45 days before following up with
     Medicare on an unpaid claim.

I have been informed of Hilltop Medical Clinic's policy in regards to me, the Medicare patient.  The entire bill will be strictly my responsibility to pay today.

**SIGNATURE -TO BE DONE AT THE FRONT COUNTER ELECTRONICALLY