Authorization for Information Sharing

PLEASE READ THE FOLLOWING TERMS CAREFULLY. THIS IS A LEGALLY BINDING AGREEMENT ALLOWING TRAVELRX, THE TELEHEALTH PROVIDER, AND THE PHARMACY TO SHARE YOUR INFORMATION WITH EACH OTHER FOR PURPOSES OF PROVIDING YOUR REQUESTED SERVICES.

The Services

You have requested that TravelRx coordinate the provision of certain services to you, including matching you with a provider for a telehealth consult and a pharmacy to fill any prescriptions issued by such provider (the “Services”).

Customer Data

For purposes of this Authorization, “Customer Data” means information about you that is (i) collected by TravelRx, including information submitted by you to TravelRx in the course of requesting the Services, (ii) information from the telehealth provider with whom you are matched by TravelRx (the “Telehealth Provider”), including but not limited to information about any prescriptions issued to you by the Telehealth Provider, and (iii) information from the pharmacy selected by TravelRx (the “Pharmacy”) regarding the filling of requested prescriptions. Some or all of the Customer Data may be individually identifiable information that is subject to protection from disclosure under state or federal law or may be “Protected Health Information” subject to the protections of HIPAA (the Health Insurance Portability and Accountability Act of 1996, as amended) against unauthorized use or disclosure.

Authorization

By giving your express written consent below, you hereby authorize TravelRx, the Telehealth Provider, and the Pharmacy to share Customer Data with each other as necessary in order to provide the Services requested by you.

Your rights regarding this authorization

You acknowledge that you have the right to revoke this authorization at any time, except to the extent that Customer Data has already been used and disclosed by TravelRx, the Telehealth Provider, or the Pharmacy in reliance on this authorization. You understand that if you wish to revoke this authorization in the future, you must do so in writing by sending a dated and signed letter stating that you revoke this authorization to TravelRx at the following address: 2418 SW 18th Ave, Miami, FL 33145. Unless revoked by you in writing, this Authorization shall expire three years from the date it is signed by you, or sooner if required by applicable state law. You may inspect a copy of the Customer Data used or disclosed pursuant to this Authorization by contacting us via email at support@travelrx.com.