Completion of this document authorizes the use and/or disclosure (sharing) of my identifiable health information, set forth below, consistent with federal and state law concerning the privacy of such information. I hereby authorize the use or disclosure of my health information as follows: Patient’s Name: Test, Test Persons/organizations authorized to disclose (share) the information: DigitalOptometrics LLC and its affiliated health care practitioner(s) (collectively, “DigitalOptometrics”). Persons/organizations authorized to receive, use, and further disclose (share) the information: the clinic where I am physically located to receive my eye examination through the Platform. Purpose of requested use or disclosure: to obtain corrective eye glasses, contacts and/or referral to a health care professional for further examination and treatment. This Authorization applies to the following information: Copies of my health records maintained by DigitalOptometrics, including records relating to my eye examination(s), testing results, reports, eye photos and eye corrective prescriptions. EXPIRATION: this Authorization will expire when I revoke (cancel) it or on December 31, 2060, if I do not revoke it before then. NOTICE OF RIGHTS AND OTHER INFORMATION I do not have to sign this Authorization. My treatment, payment for treatment, insurance enrollment, or eligibility for insurance benefits will not be directly affected if I do not sign this form. I am entitled to a copy of this signed Authorization. I may revoke (cancel) this Authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered to DigitalOptometrics at info@digitaloptometrics.com. My revocation (cancellation) will be effective upon receipt, but will not be effective to the extent that DigitalOptometrics or others have acted in reliance upon this Authorization. Information disclosed pursuant to this Authorization could be re-disclosed by recipients and may no longer be protected by federal confidentiality law (the Health Insurance Portability and Accountability Act or “HIPAA”). Your Information. Your Rights. Our Responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Your Rights You have the right to: Get a copy of your paper or electronic medical record Correct your paper or electronic medical record Request confidential communication Ask us to limit the information we share Get a list of those with whom we've shared your information Get a copy of this privacy notice Choose someone to act for you File a complaint if you believe your privacy rights have been violated Your Choices You have some choices in the way that we use and share information as we: Tell family and friends about your condition Provide disaster relief Include you in a hospital directory Provide mental health care Market our services and sell your information Raise funds Our Uses and Disclosures We may use and share your information as we: Treat you Run our organization Bill for your services Help with public health and safety issues Do research Comply with the law Respond to organ and tissue donation requests Work with a medical examiner or funeral director Address workers' compensation, law enforcement, and other government requests Respond to lawsuits and legal actions Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say deny your request, but we'll tell you why in writing within 60 days. Request confidential communications You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say "yes" to all reasonable requests. Ask us to limit what we use or share You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information. Get a list of those with whom we've shared information You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated You can complain if you feel we have violated your rights by contacting us using the information on page 1. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint. Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care Share information in a disaster relief situation Include your information in a hospital directory If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: Marketing purposes Sale of your information Most sharing of psychotherapy notes In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. Bill for your services We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues We can share health information about you for certain situations such as: Preventing disease Helping with product recalls Reporting adverse reactions to medications Reporting suspected abuse, neglect, or domestic violence Preventing or reducing a serious threat to anyone's health or safety Do research We can use or share your information for health research. Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law. Respond to organ and tissue donation requests We can share health information about you with organ procurement organizations. Work with a medical examiner or funeral director We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers' compensation, law enforcement, and other government requests We can use or share health information about you: For workers' compensation claims For law enforcement purposes or with a law enforcement official With health oversight agencies for activities authorized by law For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. Important We never market or sell personal information This notice is immediately effective UNLESS YOU SIGN HERE, NO INFORMATION ABOUT ALCOHOL/SUBSTANCE ABUSE, GENETIC TESTING, HIV/AIDS OR MENTAL HEALTH WILL BE DISCLOSED.

Per the Federal Trade Commission (FTC) Contact Lens Rule and Glasses Rule: All prescribers must immediately give a copy of glasses, contact lens, or both prescription(s) to the patient at the end of an eyeglass exam and/ or contact lens fitting — even if the patient doesn’t ask for it, unless the patient specifically refuses the prescription, in which case the prescriber should make a note of their refusal in the patient file. In addition, if a prescriber who sells glasses and/or contact lenses, they must ask patients to sign a statement confirming they received a copy of their prescription(s). Prescribers may provide the prescription(s) digitally if the patient agrees to receive it digitally instead of on paper by digital delivery method(s) available (for example, e-mail, or portal). If providing the prescription(s) via portal, access to the prescription(s) should remain available as long as the prescription(s) is/are valid and/or unexpired. Prescribers cannot require patients to do the following in exchange for a copy of the contact lens or glasses prescription(s): buy contact lenses or glasses, pay additional fees beyond the exam, contact lens fitting, or evaluation fee(s) collected beforehand, or sign a waiver or release form. Prescriber must give a contact lens and/or glasses prescription to anyone who is designated to act on behalf of the patient, including contact lens sellers, within 40 business hours (unless it is invalid or expired). If prescribing a private label contact lens, prescribers must include on the prescription the name of the manufacturer, trade name of the private label brand, and, if applicable, trade name of equivalent brand name. Prescribers are required to keep records or proof whether or not a patient agreed to digital delivery of their Prescription(s) for at least 3 years. Sellers must not: Fill a prescription unless they have a copy of it or have verified it, as required by the Rule Fill a prescription that the prescriber tells them, by direct communication within eight business hours after getting a complete verification request, is inaccurate, expired, or otherwise invalid Alter prescriptions. If they submit a verification request for a brand that is not the customer’s prescribed brand, they may be violating the Rule by altering the prescription. The only exception is if the seller submitted a verification request for a brand that the customer expressly told them is listed on their prescription. To qualify for this exception, the patient must be asked to give the manufacturer or brand listed on their prescription, and the customer must have told them that information. For private label lenses, however, a seller can substitute identical contact lenses made by the same manufacturer and sold under a different name Suggest or state that customers can get contact lenses without a valid prescription either in their possession or on file with their prescriber. Fill additional shipments of lenses once the prescriber has let the seller know that the prescription provided in the verification request was inaccurate, expired, or invalid, without re-verifying the request or getting a copy of the patient’s valid prescription. BY SIGNING, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THE CONTENTS OF THIS FORM IN ACCORDANCE WITH THE FTC CONTACT LENS RULE AND GLASSES RULE RESPECTIVELY. I UNDERSTAND THAT I AM ABLE TO REQUEST A PAPER AND/OR DIGITAL COPY OF MY PRESCRIPTION(S) ANY TIME WHILE IT IS STILL VALID AND UNEXPIRED.

By signing, I authorize the use and disclosure of my name, photographic/video images, and/or testimonial for marketing purposes by the practice listed below. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations. PURPOSE: The photographic/video images, and/or testimonial will be used for: Social Media and/or Social Media Advertising. REVOCABILITY: I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice via registered mail. Revocation affects disclosure moving forward and is not retroactive. This authorization expires 99 years from date signed. NO TREATMENT CONDITIONS: I understand that the practice cannot condition treatment on whether or not I sign this authorization.