Patient: the patient Date of birth: — Authorized recipient: your clinic

1. Purpose & scope. I, the patient, authorize my current and prior healthcare providers, hospitals, laboratories, imaging centers, pharmacies, and health plans to disclose my protected health information (PHI) to your clinic ("the Clinic") and its authorized agents, including Ownity, Inc. (“Ownity”), for the purpose of treatment, care coordination, and continuity of care.

2. Information covered. This authorization applies to my medical record, including but not limited to: office and visit notes, history and physical exams, laboratory and pathology results, diagnostic imaging reports, medication and prescription history, problem and allergy lists, immunization records, discharge summaries, and consultation reports.

3. Electronic network retrieval. I authorize the Clinic and Ownity to electronically locate and retrieve my existing medical records from my other providers and from connected health information networks (including Carequality and CommonWell) on my behalf, for my care. This item is optional — I may decline it below without affecting my care.

4. Specially protected records. Records that receive special protection under federal or state law — including psychotherapy notes, substance use disorder treatment records (42 CFR Part 2), HIV/AIDS, genetic information, and reproductive health — are not released under this general authorization and require separate, specific written consent.

5. Re-disclosure. I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may then no longer be protected by federal privacy law. The Clinic and Ownity will not sell my information or use it for marketing.

6. Expiration. This authorization expires 90 days from the date of signature, or on any earlier date or event I specify, unless I revoke it sooner.

7. Right to revoke. I may revoke this authorization at any time by submitting a written request to the Clinic. Revocation will not apply to information already disclosed in reliance on this authorization.

8. Voluntary. Signing this authorization is voluntary. My treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign, except where the law permits.

9. Copy. I am entitled to a copy of this signed authorization.

By signing below, I certify that I have read and understand this authorization, that I am the patient named above (or that patient's authorized personal representative), and that the information I have provided is true.

— End of authorization —