HIPAA ACKNOWLEDGEMENT AND CONSENT

I. CONSENT FOR TREATMENT: I hereby consent to the performance of medical treatment as deemed necessary or advisable by my physician(s) at Baker Health. I hereby consent to the performance of all nursing and technical procedures and tests as directed by my physician(s) at Baker Health. I understand that my medical care may require the collection of samples, including fluids or tissues, from my body. This may include having blood drawn or tissues removed during tests, treatment, or surgery. Further, I understand that should any medical personnel or other person(s) be exposed or report an exposure to my blood or body fluids, my blood will be tested for blood borne infections including Hepatitis B and C as well as HIV/AIDS. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as a result of treatments or examination. I have the right to refuse tests or treatment (as far as the law allows) and to be told what might happen if I do. I have the right not to have any photos or videos taken of me unless I agree to this, except as needed to treat me. I intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended. This consent will remain in full force until revoked in writing.

II. NOTICE OF PRIVACY PRACTICES: Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you. The notice contains a Member Rights section describing your rights under the law. You have the right to review our notice

before signing this acknowledgement. The terms of our notice may change. If we change our notice, you may request a revised copy by contacting our office or you will receive a new notice the next time you are treated at our office. Baker Health provides this form to comply with the Health Information Portability and Accountability Act of 1996 (HIPAA).

The Member understands that:

• Baker Health has a Notice of Privacy Practices and that the Member has the opportunity to review this notice.
• Protected health information may be disclosed or used for treatments payment or health care operations.
• Baker Health reserves the right to change the notice of privacy practices.

I give permission for my protected health information to be disclosed for purposes of communicating results, findings, and care decisions my primary care physician(s), specialty care physician(s), and/or any health care provider(s) or facility(ies) to facilitate my treatment and continuity of care. Please note that this does not allow these individuals to obtain copies of my medical records without a complete and valid authorization from me.

III. ELECTION TO ELECTRONICALLY TRANSMIT MEDICAL INFORMATION: I authorize Baker Health to provide a copy of the medical record of my treatment and a summary of care record to my primary care physician(s), specialty care physician(s), and/or any health care provider(s) or facility(ies) to facilitate my treatment and continuity of care. I understand that information disclosed under this paragraph may include, among other things, confidential HIV-related information and other information relating to sexually transmitted or communicable diseases, information relating to drug or alcohol abuse and/or dependence mental or behavioral health information (excluding psychotherapy notes), genetic testing information, and/or abortion-related information.

IV. PARTICIPATION IN HEALTH INFORMATION EXCHANGE(S): Federal and state laws may permit Baker Health to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share my health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of my health records; decreasing the time needed to access my information; aggregating and comparing my information for quality improvement purposes; and such other purposes as may be permitted by law. I hereby authorize Baker Health to provide a copy of my medical record or portions thereof to any health information exchange or network with which Baker Health participates and to any other participant in such health information exchange or network for purposes of treatment, payment, health care operations, and the purposes discussed above, and in accordance with the terms of the participation agreement for that health information exchange or network. A full list of health information exchanges and/or networks with which Baker Health participates may be found in the Notice of Privacy Practices, which is available on Baker Health’s website. The list may be updated from time to time if and when Baker Health participates with new health information exchanges or networks. I understand that information disclosed under this paragraph may include, among other things, confidential HIV-related information and other information relating to sexually transmitted or communicable diseases, information relating to drug or alcohol abuse and/or dependence, mental or behavioral health information (excluding psychotherapy notes), genetic testing information, and/or abortion-related information. I understand that I may, by placing my request in writing to the Privacy Officer, revoke this authorization at any time. However, I understand that a healthcare organization cannot take back information that has already been released under this authorization. This authorization will expire upon revocation.

V. EMAIL AND TEXT COMMUNICATIONS: If at any time I provide an email or text address at which I may be contacted or download and access the Baker Health mobile application, I consent to receive calls or text messages or texts via the Baker Health mobile application, including but not restricted to communications regarding billing and payment for items and services, unless I notify Baker Health to the contrary in writing. In this section, calls and text messages include but are not restricted to pre-recorded messages, artificial voice messages, automatic telephone dialing devices, text messages via the Baker Health mobile application or other computer-assisted technology, or by electronic mail, text messaging, or by any other form of electronic communication from Baker Health, its affiliates, contractors, services, clinical providers, attorneys, or agents, including collection agencies. Baker Health may contact me via email and/or text messaging and/or texts on the Baker Health mobile application to remind me of an appointment, to obtain feedback on my experience with Baker Health’s healthcare team, and to provide general health reminders/information.

VI. AUTHORIZATION TO RELEASE INFORMATION: If I am covered by Medicare or Medicaid, I authorize the release of healthcare information to the Social Security Administration or its intermediaries or carriers for payment of a Medicare claim or to the appropriate state agency for payment of a Medicaid claim. I understand Baker Health does not participate in Medicaid. I certify the information given by me in applying for payment under Title XVIII of the Social Security Act (Medicare) is correct. I request that payment of assignment benefits be made on my behalf.