HIPAA Privacy Authorization

I hereby authorize Information Technology by Medical Doctors, LLC d/b/a itMD ("itMD") to share the medical images and other protected health information uploaded to my itmd.net account limited to those covered entities and individuals I designate. itMD will only release my images and information at my direction and for the express purpose of coordinating medical care with providers that I select.

I understand and agree this authorization permits the disclosure of health-related information about me to the entities and individuals I designate and may contain sensitive information relating to the following:

• Mental health
• Communicable diseases (including HIV and AIDS)
• Alcohol/drug abuse treatment
• Other diseases

I understand and agree that this authorization also covers any record that was created by a physician or other health care provider other than the originating provider.

This authorization will remain in effect and permit the ongoing disclosure by itMD of information in the itmd.net system until I delete my account entirely or revoke this authorization. I may revoke this authorization in writing at any time. I understand that my revocation will not apply to actions already taken in reliance on my prior authorization.

I understand and agree that in addition to the information I choose to share, itMD may only share information in the limited circumstances described in the itMD Notice of Privacy Practices, which I have had an opportunity to review and to receive a copy.

I understand that I may request a copy of this authorization at any time.

Date of Agreement: 04/24/2024

Release Revision Date: 10/2011