AUTHORIZATION FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION

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 Dr. B Medical Group (DE), P.A. and all members of its affiliated covered entity (collectively, the “Dr. B Medical Group”), to disclose the existence and contents of any letter of medical necessity obtained from the Dr. B Medical Group, to my fitness or health club, facility, studio or similar establishment, and any third-party service provider to the foregoing.

This Authorization is valid until the first to occur of: (i) the date that I am no longer a patient of the Dr. B Medical Group, (ii) the five-year anniversary of the date written below, and (iii) the maximum duration permitted under applicable state law. Notwithstanding the foregoing, I understand that I have the right to revoke this Authorization at any time by sending written notice to the Dr. B Medical Group.

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. The Dr. B Medical Group 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 health 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. I have read the above information and authorize the disclosure of my information by the Dr. B Medical Group for the purpose described herein.