HIPAA Authorization to Use and Disclose Protected Health Information

Version: 19-Mar-2025

I, hereby authorize the use and/or disclosure of the protected health information about me described below ("PHI") to Geno.Me, Incorporated (“Geno.Me”). The PHI that may be used and/or disclosed are the clinical summary, which includes but is not limited to consultation notes, discharge summary notes, history & physical, imaging narratives, laboratory report narratives, pathology report narratives, procedure notes, progress notes.

This authorization shall remain in effect unless I revoke it in writing prior to that time. The covered entity that is releasing my PHI under this authorization will not receive direct or indirect remuneration in exchange for disclosing my PHI and will provide my PHI only to Geno.Me and to no other business or individual. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this form. I understand that, as set forth in the notice of privacy practices, I have the right to revoke this authorization, in writing, at any time, except to the extent that Geno.Me, Inc. has acted in reliance upon it, by sending written notification to support@yourgeno.me. I understand that I am under no obligation to consent to this authorization and that I am doing so upon my own free will. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I provide consent.