AGREEMENT

UNITED RX, LLC agrees to provide medications and other pharmaceutical items as ordered by the patient’s physician in accordance with the following terms:

1. The responsible party as noted above shall pay UNITED RX, LLC for all charges incurred as a result of the medication and/or pharmaceutical items ordered by the patient’s physician or nurse.
   • Should UNITED RX, LLC be advised, via bona fide notice, of the patient’s eligibility and coverage by state medical assistance program, charges for services covered by the medical assistance program party shall remain liable for charges not covered by the state medical assistance program.
   • Payment for services rendered is due within fifteen (15) days of the billing date. If said bill is not paid in full within thirty (30) days of the billing date, a penalty of one and one half (1 & ½) percent (minimum $1.50) per month will be assessed on the unpaid balance. In the event that the services of a collection agency as well as any legal fees incurred by UNITED RX, LLC in connection with collection with an outstanding bill.
2. Permission Statement: UNITED RX, LLC is granted permission to bill the named payer identified above for medications and/or pharmaceutical items furnished for the care of the client named above. * IN THE EVENT THAT THE RESPONSIBLE PARTY FAILS TO MAKE FULL PAYMENT FOR PHARMACEUTICALS SUPPLIED, UNITED RX, LLC RESERVES THE RIGHT TO TERMINATE SERVICES.
   The information furnished above is true, complete and correct, and is submitted for the purpose of obtaining credit. The applicant / customer / Guarantor above-listed authorizes UNITED RX, LLC to gather whatever credit information it considers necessary and appropriate to reach a credit decision. If the requested credit is granted, applicant / customer / guarantor also authorize UNITED RX, LLC to give information to others. The applicant / customer / guarantor understands UNITED RX, LLC will consider this application to be a continuing statement of financial condition and agrees to notify UNITED RX, LLC in writing of any material change in fact or financial condition.
   Pursuant to the Application for Credit, applicant / customer / guarantor above-listed agrees that in the event that the applicant / customer / guarantor Defaults in the payment of any installment due or payment due UNITED RX, LLC pursuant to the agreed payment terms as invoiced by UNITED RX, LLC or as herein provided at anytime during the term of this agreement, or defaults in the performance of any other of the Terms and conditions hereof, all sums due UNITED RX, LLC from the debtor applicant / customer / guarantor as herein provided shall Immediately become due and payable and shall be paid and discharged by the debtor, anything to the contrary here notwithstanding. In the event that the debtor thereupon fails to repay the sums due in full with interest thereon as herein provided, UNITED RX, LLC may then take such steps as are legally available to them for the collection of any sums so due and is not confined to the remedies set forth herein. Applicant / customer / guarantor, above-listed, hereby stipulate that if any action is necessitated as a result of any debt owed by applicant / customer / guarantor to UNITED RX, LLC then applicant / customer / guarantor agrees that said action may be filed in the Circuit Court of COOK COUNTY, Illinois for any debt obligation owing by applicant / customer / guarantor. Further, said applicant / customer / guarantor stipulates and agrees that this Application for Credit has been made at the business location of UNITED RX, LLC. in Hillside, Illinois and performance of the contractual obligations between all parties is at the UNITED RX, LLC location at Hillside, Illinois. Further, applicant / customer / guarantor stipulates that for any action brought to collect a debt within the Circuit Court of Cook County Judicial Circuit jurisdiction that said action may be brought in the Small Claims Courthouse of Cook County or at the Maywood Courthouse. Further, applicant / customer / guarantor acknowledges and agrees that it shall pay all costs and expenses of UNITED RX, LLC including all reasonable attorney’s fees in connection with the collection of all debt owed by applicant / customer / guarantor to UNITED RX, LLC pursuant to this agreement and credit application and guaranty provide

   UNITED RX BILLING DEPT. can be contacted at: 708-449-7600