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Continuwell

Patient Consent to Use and Disclose Health Information

for Treatment, Payment and Operations

By your electronic signature below, you are consenting to the Use and Disclosure of your health information (which includes information about your health or condition and the treatment provided to you) by Continuwell (“CW”) and its associated physicians, nurse practitioners, nurses, and other health care providers and agents for healthcare treatment, payment and operations purposes, consistent with CW’s Notice of Privacy Practices. You also acknowledge that you have received a copy of CW’s Notice of Privacy Practices.

This consent is valid for] one year from the date you sign. If at any time you change your mind about permitting CW to use or disclose your health information for healthcare treatment, payment and operations, you can withdraw your consent. Withdrawing your consent will not apply to any uses or disclosures of your health information already made by CW. Further, if you do not permit CW to use or disclose your health information for healthcare treatment, payment and operations, CW may not be able to provide services to you. You have the right to request certain restrictions on the use or disclosure of your information for treatment, payment and operations purposes, as described in the Notice of Privacy Practices.

If you have questions about any of the above statements, please ask a CONTINUWELL team member.