Under the “Good Faith Estimate for Health Care Items and Services” No Surprises Act 2799B-6 of the Public Health Service Act and its implementing regulations, health care providers are required to provide a good faith estimate of expected charges for items and services to individuals who do not have insurance or who are not using insurance upon request or at the time of scheduling health care items and services. A good faith estimate must be provided within 1 business day of the scheduled service to be provided or before the service is scheduled if requested.

For more information regarding the No Surprises Act visit:

www.cms.gov/nosurprises.

Agreement between user and MRI of Springfield

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.

OUR OBLIGATION TO YOU:

We are committed to protecting the privacy of your medical information. We are required by law
to maintain the confidentiality of information that identifies you and the care you receive. We are
required to give you this notice of our legal duties, our privacy practices and your rights, and we
must also follow the terms of this Notice.

WE USE AND DISCLOSE INFORMATION:
For treatment, we give information to doctors regarding test results and record that information
for others to use.

For payment, we may contact your insurer to verify what benefits you are eligible for, obtain
prior authorization, and tell them about your treatment to make sure they will pay for your care.

We will also use or disclose information to obtain payment from third parties that may be
responsible for payment.

For health care providers for their treatment, payment and operations as to your care by them.
For appointments to remind you of an appointment or tell you about health-related benefits or
services.

With your written authorization you may revoke any authorization at any time, in writing, but only
as to future uses or disclosures, and only if we have not already acted in reliance. We may use
or disclose medical information for purposes not described in this Notice only with your written
authorization.

OTHER USES AND DISCLOSURES WE MAY MAKE WITHOUT AUTHORIZATION:
As required by law to the extent and under the circumstances provided in such law.

To report abuse, or neglect if we believe you may be a victim. We will tell you in advance unless
we think that would place you at risk for serious harm.

In judicial proceedings in response to court or administrative orders; or subpoenas, discovery
requests, or other process after reasonable efforts to notify you or obtain a protective order.

For workmans compensation or similar programs, as required by the applicable laws.

To request a restriction on uses and disclosures. We are not required to agree with your
request. If we do not agree with the request, we will comply with your request except to the
extent that disclosure has already occurred or if you are in need of emergency treatment and
the information is needed to provide the emergency treatment.

To inspect and request a copy of your health record except in limited circumstances defined by
federal regulations. A fee will be charged to copy your record. If you are denied access to your
health record for certain reasons, we will tell you why and what your rights are to challenge that
denial.

To request contact by alternate means (i.e. Fax versus mail) or at alternate locations (address
or phone number). Your request must be in writing, and we must honor it if reasonable.

CONTACT:
To exercise any of the above rights, or if you have any questions, contact MRI of Springfield,
Inc. 417-885-1100.

CHANGES TO THIS NOTICE:
We reserve the right to change this Notice. We reserve the right to make the revised or changed
Notice effective for information we already have about you as well as any information we
receive in the future. We will post a copy of the current Notice in our facilities and on our Web
site. A copy of the current Notice in effect will be available at our registration areas and it is
available upon request.

The mriofspringfield.com website (the “Site”) is comprised of a web page operated by MRI of
Springfield, Inc (“MRI of Springfield”). Mriofspringfield.com is offered to you conditioned on your
acceptance without modification of the terms, conditions, and notices contained herein (the “Terms”).

Your use of mriofspringfield.com constitutes your agreement to all such Terms. Please read these
terms carefully and keep a copy of them for your reference.

The site is for the purpose of providing information regarding the services we provide and not
intended as medical advice.

Your use of mriofspringfield.com is subject to MRI of Springfield’s Privacy Policy which also governs
the Site and informs users of our data collection practices.

Using mriofspringfield.com or sending emails to MRI of Springfield constitutes electronic
communications. You consent to receive electronic communications, and you agree that all
agreements, notices, disclosures and other communications that we provide to you electronically, via
email and on the Site, satisfy any legal requirement that such communications be in writing.

The site may contain links to other websites (“Linked Sites”). The Linked Sites are not under the
control of MRI of Springfield. MRI of Springfield is not responsible for the contents of any Linked Site,
including without limitation any link contained in a Linked Site, or any changes or updates to a linked
site.

You are granted a non-exclusive, non-transferable, revocable license to access and use
mriofspringfield.com strictly in accordance with these terms of use. As a condition of your use of the
site, you agree that you will not use the Site for any purpose that is unlawful or prohibited by these
terms. You may not use the Site in any manner which could damage, disable, overburden, or impair
the Site or interfere with any other party’s use and enjoyment of the Site. You may not obtain or
attempt to obtain any materials or information through any means not intentionally made available or
provided for through the Site.

All content included as part of the Site, such as text, graphics, logos, images, as well as the
compilation thereof, and any software used on the Site, is the property of MRI of Springfield and is
protected by copyright and other laws that protect intellectual property and proprietary rights. You
agree to observe and abide by all copyright and other proprietary notices, legends or other
restrictions contained in any such content and will not make any changes thereto.

You will not modify, publish, or in any way exploit any of the content, in whole or in part, found on the
site. Your use of the Site does not entitle you to make any unauthorized use of any protected content,
and in particular you will not delete or alter any proprietary rights or attribution notices in any content.
You will use content solely for your personal use and will make no other use of the content without the
express written permission of MRI of Springfield. You agree that you do not acquire any ownership

rights in any protected content. We do not grant you any licenses, express or implied, to the
intellectual property of MRI of Springfield except as expressly authorized by these Terms.

Indemnification

You agree to indemnify, defend and hold harmless MRI of Springfield, its officers, directors,
employees, agents and third parties, for any losses, costs, liabilities and expenses (including
reasonable attorney’s fees) relating to or arising out of your use of or inability to use the Site or
services, any user postings made by you, your violation of any terms of this Agreement or your
violation of any rights of a third party, or your violation of any applicable laws, rules or regulations.

MRI of Springfield reserves the right, at its own cost, to assume the exclusive defense and control of
any matter otherwise subject to indemnification by you, in which event you will fully cooperate with
MRI of Springfield in asserting any available defenses.

Liability Disclaimer

THE INFORMATION, PRODUCTS, AND SERVICES INCLUDED IN OR AVAILABLE THROUGH THE
SITE MAY INCLUDE INACCURACIES OR TYPOGRAPHICAL ERRORS. CHANGES ARE
PERIODICALLY ADDED TO THE INFORMATION HEREIN. MRI OF SPRINGFIELD MAY MAKE
IMPROVEMENTS AND/OR CHANGES IN THE SITE AT ANY TIME.
MRI OF SPRINGFIELD MAKES NO REPRESENTATIONS ABOUT THE SUITABILITY, RELIABILITY,
AVAILABILITY, TIMELINESS, AND ACCURACY OF THE INFORMATION, SOFTWARE,
PRODUCTS, SERVICES AND RELATED GRAPHICS CONTAINED ON THE SITE FOR ANY
PURPOSE. TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, ALL SUCH
INFORMATION, SOFTWARE, PRODUCTS, SERVICES AND RELATED GRAPHICS ARE
PROVIDED “AS IS” WITHOUT WARRANTY OR CONDITION OF ANY KIND.
TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, IN NO EVENT SHALL MRI OF
SPRINGFIELD BE LIABLE FOR ANY DIRECT, INDIRECT, PUNITIVE, INCIDENTAL, SPECIAL,
CONSEQUENTIAL DAMAGES OR ANY DAMAGES WHATSOEVER INCLUDING, WITHOUT
LIMITATION, DAMAGES FOR LOSS OF USE, DATA OR PROFITS, ARISING OUT OF OR IN ANY
WAY CONNECTED WITH THE USE OR PERFORMANCE OF THE SITE, WITH THE DELAY OR
INABILITY TO USE THE SITE OR RELATED SERVICES, THE PROVISION OF OR FAILURE TO
PROVIDE SERVICES, OR FOR ANY INFORMATION, SOFTWARE, PRODUCTS, SERVICES AND
RELATED GRAPHICS OBTAINED THROUGH THE SITE, OR OTHERWISE ARISING OUT OF THE
USE OF THE SITE, WHETHER BASED ON CONTRACT, TORT, NEGLIGENCE, STRICT LIABILITY
OR OTHERWISE, EVEN IF MRI OF SPRINGFIELD HAS BEEN ADVISED OF THE POSSIBILITY OF
DAMAGES. BECAUSE SOME STATES/JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR
LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, THE ABOVE
LIMITATION MAY NOT APPLY TO YOU. IF YOU ARE DISSATISFIED WITH ANY PORTION OF THE
SITE, OR WITH ANY OF THESE TERMS OF USE, YOUR SOLE AND EXCLUSIVE REMEDY IS TO
DISCONTINUE USING THE SITE.

Termination/Access Restriction

MRI of Springfield reserves the right, in its sole discretion, to terminate your access to the Site and
the related services or any portion thereof at any time, without notice to the maximum extent
permitted by law. Use of the Site is unauthorized in any jurisdiction that does not give effect to all
provisions of these Terms, including, without limitation, this section.

You agree that no joint venture, partnership, employment, or agency relationship exists between you
and MRI of Springfield because of this agreement or use of the Site. MRI of Springfield’s performance
of this agreement is subject to existing laws and legal process, and nothing contained in this
agreement is in derogation of MRI of Springfield’s right to comply with governmental, court and law
enforcement requests or requirements relating to your use of the Site or information provided to or
gathered by MRI of Springfield with respect to such use. If any part of this agreement is determined to
be invalid or unenforceable pursuant to applicable law including, but not limited to, the warranty
disclaimers and liability limitations set forth above, then the invalid or unenforceable provision will be
deemed superseded by a valid, enforceable provision that most closely matches the intent of the
original provision and the remainder of the agreement shall continue in effect.

This agreement constitutes the entire agreement between the user and MRI of Springfield with
respect to the Site and it supersedes all prior or contemporaneous communications and proposals,
whether electronic, oral or written, between the user and MRI of Springfield with respect to the Site.
Changes to Terms

MRI of Springfield reserves the right, in its sole discretion, to change the Terms under which
mriofspringifeld.com is offered. The most current version of the Terms will supersede all previous
versions.