Adept Labs, Inc. d/b/a Vital (“Vital”) provides API solutions for at-home health care. Vital contracts with enterprise customers to grant access to Vital’s services to the customers’ patients like you. As part of its service, Vital works with health care providers and lab testing facilities to facilitate sharing your protected health information as governed by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.S.C. § 1320d and 45 C.F.R. § 160–164.

This HIPAA Authorization is to authorize the disclosure of your information from Vital to the following enterprise customer: Nimbus Health. By signing below, you agree as follows:

1. Pursuant to HIPAA, I authorize and direct Vital to give, disclose, and release, without restriction, my medical records, lab order, and/or lab testing results to Nimbus Health.
2. The purpose of the uses and disclosures is for care coordination
3. I understand that, with certain exceptions, I have the right to revoke this Authorization at any time. If I want to revoke this Authorization, I must do so in writing. I may revoke this Authorization by sending an email to support@tryvital.io stating my desire to revoke my HIPAA Authorization. I understand that it may take Vital a few business days to process my revocation.
4. I understand that I may refuse to sign this Authorization, but that will prevent me from participating in Vital’s services. I also understand that my health care provider cannot deny or refuse to provide treatment, payment, enrollment in a health plan, or eligibility of benefits if I refuse to sign this Authorization.
5. I understand that, once information is disclosed pursuant to this Authorization, it is possible that it will no longer be protected by applicable federal medical privacy law and could be re-disclosed by the person or agency that receives it.
6. The authority above shall supersede any prior agreement that I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information. The authority given has no expiration date and shall expire only in the event that the enterprise contract between Vital and Vital Customer terminates or I revoke the authority in writing as specified above.

I understand that I have a right to a copy of this Authorization.

I understand that Telehealth is a mode of delivering health care services via communication technologies (e.g., internet or cellphone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care.

By acknowledging my consent below, I understand and agree to the following:

1. I understand that Vital and affiliate Openloop Healthcare Partners, PC offer Telehealth consultations, which are conducted through videoconferencing, telephonic, and asynchronous technology and my Telehealth provider will not be present in the room with me.
2. I understand there are potential risks to the use of Telehealth technology, including but not limited to, interruptions, delays, unauthorized access, and or other technical difficulties. I understand that either my Telehealth provider or I can discontinue the Telehealth appointment if the technical connections are not adequate for my visit.
3. I understand that I could seek an in-office visit rather than obtain care from a Telehealth provider, and I am choosing to participate in a Telehealth consultation with Vital, an affiliate of Openloop Healthcare Partners, PC, Openloop Healthcare Partners, PC, Openloop Healthcare Partners California, PC, Openloop Healthcare Partners Colorado, PC, Openloop Healthcare Partners New Jersey, PC, Openloop Healthcare Partners Wisconsin SC, Reliant.MD Medical Associates, PLLC, Reliant.MD Medical Associates California, PC, Reliant.MD Medical Associates Colorado, PC, Reliant.MD Medical Associates New Jersey, PC, Reliant.MD Medical Associates Wisconsin, SC, MECNB Physician Services, PC, MECNB Physician Services California, PC, MECNB Physician Services Colorado, PC, MECNB Physician Services New Jersey, PC, and MECNB Physician Services, SC.
4. To protect the confidentiality of my health information, I agree to undertake my Telehealth consultation in a private location, and I understand that my Telehealth provider will similarly be in a private location.
5. I understand that I am responsible for payment of any amounts due and owing resulting from my Telehealth visit.
6. In an emergent situation, I understand that the responsibility of my Telehealth provider may be to direct me to emergency medical services, such as an emergency room.

By acknowledging below, I certify:

• That I have read this form and/or had it explained to me
• That I understand the risks and benefits of a Telehealth appointment
• That I have been given the opportunity to ask questions and that such questions have been answered to my satisfaction.