Lab Release

I, the client, (as listed in my client account) hereby authorize Klarity Well Health and its affiliates, its employees and agents to release to the healthcare provider (as listed above) my PHI (e.g., information relating to the treatment and services provided or to be provided by me and which identifies my name, date of birth, gender, address, and lab test results).

I understand that any PHI or other information released to the person or organization identified above may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws. This authorization is valid from the date of my signature on the previous page and this information shall be considered released to the

stated party indefinitely unless a statement revoking this release is provided in writing in which the release of this information would end. I understand that I have a right to revoke this authorization by providing written notice to Klarity Well Health. However, this authorization may not be revoked if the Laboratory Vendors, its employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my services. A copy of this release will be considered as original with regard to the signature. I, the client, authorize the release of information, including a copy of digital test results, to the email address provided in my client profile.

Specific provisions for the Privacy Act and Paperwork Reduction Act:

Klarity Well Health, Corp Privacy Act and Paperwork Reduction Act Information: The execution of this form does not authorize the release of information other than that specifically described below. The information requested on this form is solicited under Title 38, U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164, 5 U.S.C. 552a, and 38, U.S.C. 5701 and 7332 that you specify. Your disclosure of the information requested on this form is voluntary. However, if the information is not furnished completely and accurately, Klarity Well Health will be unable to comply with the request. Klarity Well Health may not condition treatment, payment, enrollment or eligibility on signing the authorization. Klarity Well Health may disclose the information that you put on the form as permitted by law. The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995.