Common use of Requests for Summary Information about You Clause in Contracts

Requests for Summary Information about You. As part of making certain Services available to you at the Practice, the employer health plan under which You are enrolled may request from the Practice information about the results of any biometric screening examinations and/or health risk assessments that You have completed. In addition, the employer health plan may request summary reports concerning the utilization of Services among its enrollees who participate in the Practice. You acknowledge that such summary information will be prepared using information from the medical records maintained by the Practice about You. Authorization to Release: You authorize the Practice to use health information about You that is maintained by the Practice to prepare the summary information described in this Employer Health Plan Authorization and disclose such information in reports to the employer health plan under which You are enrolled. Term of Authorization: This authorization will be effective for as long as You are participating in the Practice through an employer health plan. Attachment C CAREGIVER DESIGNATION & AUTHORIZATION The undersigned, a patient at the Practice ("You"), designate one or more Caregivers and authorize such Caregiver(s) to engage with the Practice on Your behalf as follows: Caregiver Designation: You desire to designate the individual(s) listed below as Your Caregiver(s) for purposes of assisting with and facilitating the Services You receive from the Practice: 1. Relationship to You: Caregiver Name (Print) Phone Number: E-mail Address: 2. Relationship to You: Caregiver Name (Print) Phone Number: E-mail Address: 3. Relationship to You: Caregiver Name (Print) Phone Number: E-mail Address: Scope of Caregiver Authority: You authorize the Caregiver(s) to assist with, participate in, and facilitate all aspects of Your participation as a patient in the Practice, including, but not limited to, the following activities:

Requests for Summary Information about You. As part of making certain Services available to you You at the Practice, the employer health plan under which You are enrolled may request from the Practice information about the results of any biometric screening examinations and/or health risk assessments that You have completed. In addition, the employer health plan may request summary reports concerning the utilization of Services among its enrollees who participate in the Practice. You acknowledge that such summary information information, void of any personally identifiable data, will be prepared using information from the medical records maintained by the Practice about You. Authorization to Release: You authorize the Practice to use health information about You that is maintained by the Practice to prepare the summary information described in this Employer Health Plan Authorization and disclose such information in reports to the employer health plan under which You are enrolled. Term of Authorization: This authorization will be effective for as long as You are participating in the Practice through an employer health plan. Attachment C CAREGIVER DESIGNATION & AUTHORIZATION The undersigned, a patient Patient at the Practice ("You"), designate one or more Caregivers and authorize such Caregiver(s) to engage with the Practice on Your behalf as follows: Caregiver Designation: You desire to designate the individual(s) listed below as Your Caregiver(s) for purposes of assisting with and facilitating the Services You receive from the Practice: 1. Relationship to You: Caregiver Name (Print) Phone Number: E-mail Address: 2. Relationship to You: Caregiver Name (Print) Phone Number: E-mail Address: 3. Relationship to You: Caregiver Name (Print) Phone Number: E-mail Address: Scope of Caregiver Authority: You authorize the Caregiver(s) to assist with, participate in, and facilitate all aspects of Your participation as a patient Patient in the Practice, including, but not limited to, the following activities:activities (You may strike through any activities You decline):

Requests for Summary Information about You. As part of making certain Services available to you at the Practice, the employer health plan under which You are enrolled may request from the Practice information about the results of any biometric screening examinations and/or health risk assessments that You have completed. In addition, the employer health plan may request summary reports concerning the utilization of Services among its enrollees who participate in the Practice. You acknowledge that such summary information will be prepared using information from the medical records maintained by the Practice about You. Authorization to Release: You authorize the Practice to use health information about You that is maintained by the Practice to prepare the summary information described in this Employer Health Plan Authorization and disclose such information in reports to the employer health plan under which You are enrolled. Term of Authorization: This authorization will be effective for as long as You are participating in the Practice through an employer health plan. Attachment C CAREGIVER DESIGNATION & AUTHORIZATION The undersigned, a patient at the Practice ("You"), designate one or more Caregivers and authorize such Caregiver(s) to engage with the Practice on Your behalf as follows: Caregiver Designation: You desire to designate the individual(s) listed below as Your Caregiver(s) for purposes of assisting with and facilitating the Services You receive from the Practice: 1. Relationship to You: Caregiver Name (Print) Phone Number: E-mail Address: 2. Relationship to You: Caregiver Name (Print) Phone Number: E-mail Address: 3. Relationship to You: Caregiver Name (Print) Phone Number: E-mail Address: Scope of Caregiver Authority: You authorize the Caregiver(s) to assist with, participate in, and facilitate all aspects of Your participation as a patient in the Practice, including, but not limited to, the following activities: