HIPAA Authorization — Lab Testing

Adept Labs, Inc. d/b/a Junction (“Junction”) provides API solutions for at-home and walk-in health care. Junction contracts with enterprise customers to grant access to Junction’s services to the customers’ patients like you. As part of its service, Junction works with health care providers and lab testing facilities to facilitate sharing your protected health information as governed by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.S.C. § 1320d and 45 C.F.R. § 160–164.

This HIPAA Authorization authorizes the disclosure of your information from Junction to the following enterprise customer: AI Coaching Inc., d/b/a Gala GLP-1 (“Gala GLP-1”). By accepting this authorization, you agree as follows:

Authorization

Pursuant to HIPAA, I authorize and direct Junction to give, disclose, and release, without restriction, my medical records, lab order, and/or lab testing results to Gala GLP-1. The purpose of the uses and disclosures is for care coordination.

Your Rights

• Right to Revoke: I understand that, with certain exceptions, I have the right to revoke this Authorization at any time. To revoke this Authorization, I must submit a written request to Gala GLP-1. A revocation will not apply to information that has already been disclosed in reliance on this Authorization.
• Re-disclosure: I understand that information disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.
• Voluntary: I understand that signing this Authorization is voluntary.
• Expiration: Unless revoked earlier, this Authorization expires when my care coordination with Gala GLP-1 ends.

By checking the HIPAA Authorization box when you request a lab order, you acknowledge that you have read, understand, and agree to the terms of this HIPAA Authorization.