AUTHORIZATION AND DIRECTION TO RELEASE OF HEALTH INFORMATION 

I authorize and direct release and disclosure of my personal information, including my  health information as described in this Authorization by:  

OpenLoop Healthcare Partners, PC and its health care practitioners  (“OpenLoop”)  

who provides telehealth services to me as part of the Enhanced Performance  Program (“Program”), to the Program sponsor: Enhanced US LLC and its affiliates,  partners, contractors and agents (“Enhanced”), for the following purposes: 

• enrolling and monitoring my participation in the Program; 

• communicating with me about my participation in the Program; 

• marketing services and products to me that might be of interest to me; and • for future research, including for the creation and maintenance of a research database or research repository. 

Information to be disclosed: All personally identifiable health information, protected  health information, and other personal information, including all demographic  information, health status, diagnoses, treatment, lab results, prescription information and other information (collectively “My Information”) in the possession or control of  OpenLoop. 

This Authorization may include disclosure of sensitive information including, for  example, relating to ADDICTION TREATMENT, BEHAVIORAL HEALTH TREATMENT  (except psychotherapy notes), and REPRODUCTIVE HEALTH RELATED  INFORMATION.  

I understand that signing this Authorization is voluntary. OpenLoop may not condition  treatment, payment, enrollment in a health plan, or eligibility for benefits on my signing  of this Authorization. If I chose not to disclose My Information for participation in the  Program, I may still receive treatment services from OpenLoop’s other telehealth  programs.  

I understand that Enhanced is not a health care provider or health plan covered by  federal privacy regulations and that the My Information disclosed under this  Authorization might be re-disclosed by Enhanced and will no longer be protected by  federal privacy regulations. I understand that I have the right to receive a copy of this  Authorization. 

I understand that this Authorization will remain valid unless I revoke it. I understand that I have the right to revoke this Authorization, in writing, by sending notification to  OpenLoop at the following e-mail address: privacy@openloophealth.com. I understand  that a revocation is not effective to the extent that action has already been taken based  on this Authorization.  

I authorize and direct OpenLoop to share My Information to Enhanced as part of the Program.