HIPAA Authorization to Use and Disclose Information

I hereby authorize the use and disclosure of my individually identifiable information as described below. I understand that this authorization is voluntary. I understand that if the organization or person authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by HIPAA.

Organizations from whom Porter Cares, Inc. (“Porter”) may request and obtain the information: All individuals and entities thatprovide healthcare services to me or provide payment for such healthcare services to me including, but not limited to, health plans and their affiliates

Organizations or persons to whom Porter may disclose the information: Porter’s suppliers of services that Porter is trying to find on your behalf, third party contractors (both entities and individual independent contractors) who contract with Porter to supplyservices to you on behalf of Porter, and your caregiver.

Specific description of information to be obtained, used and disclosed: Information regarding your insurance coverage and health condition(s) which will be used according to Porter’s privacy policy which can be found at www.helloporter.com.

Reason for use or disclosure of information: To assist Porter in providing you with third-party insurance coverage insightsand third-party products and services.

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I understand that I will not be denied health care or health plan coverage, as the case may be, if I do not sign this form; however, Porter may not be able to provide some services if I do not sign this form.

I understand that I may obtain the information described on this form if I ask for it, and that I may print copy of this form after I sign it.

I understand that this authorization will expire when I no longer participate in Porter’s service offerings.I understand that Imay revoke this authorization at any time by emailing my request to [email protected], but if I do, it will not affect any actions taken before the revocation is received.

A photocopy of the original electronic form of this authorization shall have the same effect as that original electronic form.