HIPAA Authorization

Purpose of this authorization

I authorize the laboratory, medical group, or other covered-entity healthcare provider identified below (the “Disclosing Provider”) to disclose my protected health information to Prescripa LLC, a Florida limited liability company (“Prescripa”) and to the licensed medical practice (the brand’s own practice, or LB Medical Services, a separately owned professional association) treating me (the “Practice”), and to allow the Practice and its clinicians to access that information through the Prescripa platform, for care-coordination purposes.

I understand that this authorization is voluntary, and that I may refuse to sign it. My refusal to sign, or my later revocation, will not affect my eligibility for treatment, payment, benefits, or services I am otherwise entitled to receive. If I decline to sign, the Disclosing Provider may not be able to share certain health information with Prescripa or the Practice, which may limit the Practice's ability to coordinate my care.

What “protected health information” means

“Protected health information” (“PHI”) has the meaning given to it by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”): identifiable information relating to (a) my past, present, or future physical or mental health or condition; (b) the provision of health care to me; and (c) payment for the provision of health care to me. PHI may include information created before or after the date I sign this authorization.

Information to be disclosed

I authorize the disclosure of the categories I select in the portal:

• Health reports and clinical assessments
• Laboratory and diagnostic test results
• Prescription information and prescription orders
• Other information I specifically identify

Sensitive information is excluded

Disclosing Provider and Practice

The authorization identifies, in the portal at the time of signature: the name of the Disclosing Provider, and the name of the Practice authorized to receive and access the information. Prescripa’s contact for this authorization is support@prescripa.com, marked “Attn: Privacy Officer.”

How the information will be used

The information disclosed under this authorization will be used to coordinate my care: to give the treating clinician the clinical context needed to evaluate my request, to maintain an accurate record of the clinical decision, and to support fulfillment of any prescription that clinician issues. Prescripa will not use or disclose this information for marketing, and will not sell it.

Expiration

This authorization expires the earlier of: (a) one year from the date I sign it; (b) the date my relationship with the Practice ends; or (c) the date I revoke it in writing. A shorter period may be specified at the time of signature.

My right to revoke

I may revoke this authorization at any time by writing to the Practice or to Prescripa at support@prescripa.com, marked “Attn: Privacy Officer.” Revocation takes effect when it is received, and does not apply to information that was already disclosed while the authorization was in effect.

Redisclosure

I understand that information disclosed under this authorization may, once received, no longer be protected by federal privacy rules and could be redisclosed by the recipient. Prescripa handles the information it receives as a business associate of the Practice, under a written Business Associate Agreement and as described in its Privacy Policy.

Signature

The executable version of this authorization records the patient's name, the patient's date of birth, the electronic signature, the date and time of signature, and, where the person signing is a personal representative, that person's name and authority to act.

Questions

Questions about this authorization can be directed to support@prescripa.com, marked “Attn: Privacy Officer,” or to the practice treating you.