HIPAA Authorization

I hereby authorize the laboratory, medical group, or other covered entity healthcare provider identified below (the “Disclosing Provider”) to disclose my protected health information to Lyv Health, Inc. DBA Altro Health (“Altro Health”) and my Wellness Partner(s) identified below the ability to access my protected health information through the altro Health platform interface (the “Platform”), for care coordination purposes. I understand that this Authorization for Disclosure of Protected Health Information (“Authorization”) is voluntary, and I may refuse to sign this Authorization. My refusal to sign, or my revocation of this Authorization, will not affect my eligibility for any treatment, payment, benefits, or services that I am otherwise entitled to receive or participate in. If I decline to sign this Authorization, the Disclosing Provider may not be able to share certain health information with altro Health, limiting the ability of altro and my Wellness Partner to access certain health information that may be relevant to altro’s ability to provide care coordination services and the Wellness Services I receive through the Platform.

“Protected health information” referred to in this Authorization means protected health information as that term is defined under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). HIPAA defines “protected health information” as identifiable information relating to (a) my past and present 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. Protected health information may include information created both before and after the date of this Authorization. Please note that certain sensitive categories of protected health information are expressly excluded from this Authorization and will not be disclosed to altro Health or my Wellness Partner under any circumstances, as described in the notice below.

PROTECTED HEALTH INFORMATION TO BE DISCLOSED
□         Health Reports and Wellness Assessments
□         Lab and Diagnostic Test Results
□         Prescription Information and Prescription Orders
□         Other

NOTICE: SENSITIVE HEALTH INFORMATION IS EXCLUDED FROM THIS AUTHORIZATION. To protect your privacy, this Authorization does not cover, and neither the Disclosing Provider nor altro Health will disclose, the following sensitive categories of protected health information, regardless of the selections made above: (i) Mental health and psychiatric records, including any records protected under 42 C.F.R. Part 2 (substance use disorder treatment records); (ii) HIV/AIDS status, testing, diagnosis, or treatment records; (iii) Reproductive health information, including records relating to abortion, contraception, fertility treatment, or pregnancy; and (iv) Genetic information. For questions about how altro Health handles sensitive health information, please contact Altro Health at hello@altrohealth.com

DISCLOSING PROVIDER INFORMATION

I authorize the following laboratory, medical group, or other covered entity healthcare provider to disclose the categories of protected health information selected above to Altro Health, Inc.,
Email: hello@altrohealth.com | Attn: Privacy Officer:
Name of Disclosing Provider: Hinds4Health
Wellneess Partner

I authorize altro Health to make the categories of protected health information selected above available for limited access, solely through the Platform, to my Wellness Partner currently active on the Platform to whom I am assigned or with whom I engage for Wellness Services, while such Wellness Partner(s) are actively logged in to the Platform.

PURPOSE OF THE DISCLOSURE

□         Care coordination and treatment services provided to me through the Platform by altro Health
□         Provision of Wellness Services to me through the Platform by my designated Wellness Partner(s)

Further, if I am a resident of California, any person or entity to whom my protected health information is disclosed pursuant to this Authorization may not further use or disclose the protected health information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by applicable law.

I understand that I may revoke this Authorization at any time by: (a) sending a written revocation notice to: (i) the Disclosing Provider identified above at the address provided; and/or (ii) Altro Health at hello@altrohealth.com Attn: Privacy Officer; or (b) logging into my account on the Platform and updating my authorization settings. My revocation will be effective upon receipt by the Disclosing Provider and/or altro Health, except to the extent that the Disclosing Provider, altro Health, or my Wellness Partner has already acted in reliance on this Authorization prior to receipt of my revocation.

I acknowledge that I have read and understand this Authorization for Disclosure of Protected Health Information. I understand that I have a right to receive a copy of this Authorization upon request. This Authorization shall expire upon the earliest of: (i) the date on which my Wellness Partner’s subscription to the Platform is terminated or expires; (ii) five (5) years from the date of my signature below; or (iii) my earlier revocation of this Authorization in accordance with the revocation procedure described above.

Scope of Access: Platform-Only Disclosure

The following conditions apply to all access authorized under this Authorization form:
(a) No Downloads or Copies. My Wellness Partner is not authorized to download, print, copy, screen-capture, photograph, or otherwise extract, reproduce, or retain any of my protected health information, except for my lab results, outside of the Platform.
(b) No Offline Storage or Transmission. My Wellness Partner is not authorized to store, retain, or transmit my protected health information in any system, device, or medium outside of the Platform, including but not limited to email systems, electronic health records, CRM platforms, or personal devices.
(c) Session-Based Access Only. Access to my protected health information is permitted only during active, authenticated sessions on the Platform. My Wellness Partner’s ability to view my protected health information terminates automatically upon logout or session expiration.
(d) Technical Enforcement. altro Health implements technical controls within the Platform designed to restrict access to the conditions described above. The existence of such technical controls does not, however, limit or substitute for my Wellness Partner’s independent legal and contractual obligations to comply with this Authorization and all applicable law.

Because this Authorization is limited to view-only access through the Platform for my Wellness Partner, my Wellness Partner does not receive a transferable copy of my protected health information, which substantially reduces the risk of unauthorized re-disclosure. Nonetheless, I understand that health information disclosed under this Authorization could be subject to re-disclosure, and that such re-disclosure may no longer be protected by federal and state law, unless prohibited by more restrictive applicable law.

By signing up, I affirm that I am at least 18 years of age.