Authorization to Use and Disclose Health Information

The purpose of this authorization is to enable VitaFlow to coordinate longevity, wellness, IV therapy, peptide, NAD+, weight loss, epigenetic, and screening services on your behalf.

• Demographics and contact information
• Medical history, diagnoses, and medications
• Lab and diagnostic results, including epigenetic data
• Treatment notes and clinical plans

PHI may be used and disclosed for treatment, payment, healthcare operations, and other purposes you specifically authorize.

Authorized third parties include affiliated labs, compounding pharmacies, imaging centers, and HIPAA business associates supporting VitaFlow's operations.

You may revoke this authorization at any time by submitting a written request to privacy@vitaflow.com. Revocation does not affect actions already taken in reliance on it.

Unless otherwise specified, this authorization expires one (1) year from the date of signature or at the conclusion of the relevant treatment program, whichever comes first.

Your electronic signature, captured through the patient portal or intake forms, has the same legal effect as a handwritten signature.

• Right to refuse or revoke authorization
• Right to receive a copy of this authorization
• Right to inspect PHI disclosed under this authorization