Authorization of Use of Medical Information

Effective Date: August 4, 2025

This Authorization of Use of Medical Information applies specifically to the information provided through the Intake Form for the Concierge Service. By completing the Intake Form, you consent to the collection, use, and disclosure of your medical information as outlined below.

1. Purpose of Collecting Medical Information

The medical information you provide through the Intake Form is collected to:

• Develop a personalized health assessment and care plan.
• Provide diagnostic and treatment recommendations.
• Communicate with you regarding your participation in the Concierge Service.
• Coordinate with authorized healthcare providers, laboratories, and diagnostic services as necessary.

2. Scope of Information Collected

The following types of information may be collected through the Intake Form:

• Personal details (e.g., name, date of birth, biological sex).
• Contact information (e.g., email, phone number, emergency contact).
• Health-related information (e.g., medical history, medications, allergies, lifestyle details).
• Uploaded files (e.g., lab reports, medical records).
• Digital signature for consent and authorization.

3. Use of Your Medical Information

Your medical information will be used solely for the purposes outlined in this document. Specifically, we may use your information to:

• Analyze your health data to create a personalized care plan.
• Communicate with you regarding your health and program updates.
• Share relevant information with authorized healthcare providers and laboratories for diagnostic purposes.

Your information will not be used for marketing purposes or shared with third parties unrelated to your care without your explicit consent.

4. Disclosure of Medical Information

Your medical information may be disclosed to:

• Authorized healthcare providers involved in your care.
• Laboratories and diagnostic services for testing and analysis.
• Emergency contacts in case of a medical emergency.

All disclosures will comply with applicable privacy laws, including HIPAA (Health Insurance Portability and Accountability Act).

5. Storage and Security of Your Information

Your medical information is securely stored and accessible only to authorized personnel. We use industry-standard encryption and security measures to protect your data from unauthorized access or disclosure.

6. Revocation of Authorization

You have the right to revoke this authorization at any time by contacting us at manny@drfombu.com. Please note that revoking your authorization may limit our ability to provide certain services.

7. Retention of Medical Information

Your medical information will be retained for as long as necessary to provide services and comply with legal obligations. Once no longer needed, your information will be securely deleted or anonymized.

8. Consent

By completing the Intake Form, you acknowledge that you have read and understood this Authorization of Use of Medical Information and consent to the collection, use, and disclosure of your medical information as described.

9. Contact

If you have any questions about this authorization, please contact us at manny@drfombu.com.