By signing this Authorization, I authorize Hayek Medical ("Company") and the healthcare providers, pharmacies, laboratories, and insurers identified by me on this form to use and disclose my protected health information ("PHI") as described below.

Information to be used or disclosed: My demographic information, insurance information, prescriptions, medical records, lab results, imaging, clinical notes, treatment history, diagnoses, and any other information necessary to evaluate, coordinate, order, ship, bill, and provide follow-up for my BCV and related care.

Persons authorized to use or disclose this information: My prescribing physician(s) and their office staff, my pharmacy(ies), my insurance company(ies), and any other healthcare provider involved in my care.

Persons authorized to receive this information: Hayek Medical and its workforce members, business associates, and contracted third parties acting on its behalf, including shipping, billing, and clinical coordination partners.

Purpose: To coordinate, order, deliver, bill for, and follow up on my BCV; to communicate with my healthcare providers and insurers about my care; and at my request.

Expiration: This authorization expires one (1) year from the date of my signature, or upon completion of the services requested, whichever occurs first, unless I revoke it earlier in writing.

Right to revoke: I may revoke this authorization at any time by sending a written request to [Privacy Officer, Hayek Medical, mailing address, privacy@hayekmedical.com]. Revocation will not affect any actions Company has already taken in reliance on this authorization.

Re-disclosure: Once my information is disclosed under this authorization, the recipient may re-disclose it and federal privacy law may no longer protect it.

Conditioning: Company may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization, except as permitted by law where the requested service is solely for the purpose of creating PHI for disclosure to a third party.

Copy: I am entitled to a copy of this signed authorization.

I authorize Hayek Medical to contact my prescribing physician's office, by phone, fax, secure email, or other secure means, to:

• Confirm my BCV recommendation;
• Request and receive my medical records, prescriptions, Letter of Medical Necessity, prior authorization documentation, and any other information needed to place and fulfill my order;
• Coordinate insurance approvals and benefit verification;
• Provide updates on the status of my order.

I understand that my doctor's office may share my PHI with Hayek Medical in reliance on this authorization. I may revoke this authorization at any time in writing.