AUTHORIZATION FOR THE USE or DISCLOSUREOF‍HEALTH INFORMATION FROM RH Care, P.A.

Completion of this document authorizes the use and disclosure of health information about you. Failure to provide all information requested may invalidate this Authorization.

I hereby authorize RH Care, P.A. and the members of its affiliated covered entity ("RH Care"), located at 3031 Steiner St., Apt 2, San Francisco, CA 94123 to disclose to provider mentioned in the form:

all health information pertaining to my medical history, mental or physical condition, and treatment received, including demographic information.

I authorize the release of this information for the following purpose: To update your Primary Care Provider or Specialist on your progress and medication changes on Revero.

This Authorization is valid until I am no longer a patient of RH Care, within five (5) years from the date indicated below, or applicable state law, whichever is earlier.

I understand that I have the right to revoke this Authorization, in writing, at any time by sending such written notification to RH Care.

I understand that information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient of such information and may no longer be protected by Federal or State law. However, State law may prohibit the person receiving my health information from making future disclosures of my information unless another authorization for disclosure is obtained from me, or unless such disclosure is specifically required or permitted by law. RH Care will not condition my treatment on whether I provide authorization for the requested use or disclosure.

I understand that I have the right to: inspect or copy the protected medical information to be used or disclosed as permitted under Federal or State law; refuse to sign this Authorization; and receive a copy of this Authorization. If I am requesting information for myself or for a third party, a reasonable and appropriate fee may be assessed for copying the information. I have read the above information and authorize the disclosure of my information by RH Care for the purpose described herein.

By checking the box, you acknowledge that you have read and agree to the terms of this Authorization.