This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA) Privacy Standards.

I. MY AUTHORIZATION

I authorize Hoot Health, Inc. and my health care provider (“Provider”) to use or disclose all of my health information for the following purpose:

• For Hoot Health, Inc. or my Provider to communicate with me for marketing purposes even when Hoot Health, Inc. or my Provider receives payment from a third party to do so.

My authorization expires when I terminate my access to the Hoot Platform, which I may do by sending an email to support@ hootmyopiacare.com.

II. MY RIGHTS

I authorize Hoot Health, Inc. and my health care provider (“Provider”) to use or disclose all of my health information for the following purpose:

• I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing, and send it to Hoot Health, Inc. at support@ hootmyopiacare.com.
• I understand that uses and disclosures already made based upon my original permission cannot be taken back.
• I understand that it is possible that information used or disclosed with my permission may be redisclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.
• I understand that no party may condition my treatment, payment, enrollment or eligibility for benefits upon my signing of this authorization and that I have the right to refuse to sign this authorization.
• I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.