Vial Health Technology, Inc.

AUTHORIZATION FOR THE USE OF HEALTH INFORMATION BY VIAL HEALTH TECHNOLOGY, INC. TO MARKET TO ME

I hereby authorize Vial Health Technology, Inc. (“Vial Health”) located at 2021 Fillmore St Suite 43 San Francisco, CA 94115 to use all health information pertaining to my medical history, mental or physical condition, and treatment received, including demographic information and contact information such as my telephone number and email address, to contact me regarding clinical trials or related products and services that may be of interest to me.

This Authorization is valid until I am no longer a patient of Vial Health, for five (5) years from the date indicated below, or for the duration permitted under applicable state law, whichever is earlier.

I understand that I have the right to revoke this Authorization, in writing, at any time by sending such written notification to Vial Health.

I understand that information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient of such information and may no longer be protected by federal or state law.  However, state law may prohibit the person receiving my health information from making future disclosures of my information unless another authorization for disclosure is obtained from me, or unless such disclosure is specifically required or permitted by law.  Vial Health will not condition my treatment on whether I provide authorization for the requested use or disclosure. 

I understand that I have the right to: inspect or copy the health information to be used or disclosed as permitted under federal or state law; refuse to sign this Authorization; and receive a copy of this Authorization.  If I am requesting information for myself or for a third party, a reasonable and appropriate fee may be assessed for copying the information.  I have read the above information and authorize the disclosure of my information by Vial Health for the purpose described herein.