HIPAA Privacy Authorization

I hereby authorize Imvaria Labs to receive, use, and share the health images and other health information uploaded through this platform, to only those entities and individuals I designate, for the purpose of providing me with medical care and diagnostic services, and for the purpose of sharing my images and information with others that I select.

I understand and agree this authorization permits the disclosure of health related information about me, to the entities and individuals I so designate, and may also contain sensitive information relating to the following:

• Mental health
• Communicable diseases (including HIV and AIDS)
• Alcohol/drug abuse treatment
• Other diseases

I understand and agree that this authorization also covers any record that was created by a doctor or other health care provider other than the doctor or health care provider who supplied the record to Imvaria Labs.

This authorization will remain in effect and permit the ongoing disclosure by Imvaria Labs of information in the system until I delete my account entirely or revoke this authorization. I may revoke this authorization at any time by contacting Imvaria Labs directly. I understand that my revocation will not apply to actions already taken in reliance on my prior authorization.

I understand and agree that in addition to the information I choose to share, Imvaria Labs may only share information in the limited circumstances described in the Imvaria Labs Privacy Policy.

I understand that I may request a copy of this authorization at any time.