HIPAA Privacy Rule of Patient Authorization Agreement Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a)): I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as: • a basis for planning my care and treatment; • a means of communication among the health professionals who may contribute to my health care; • a source of information for applying my diagnosis and surgical information to my bill; • a means by which a third-party payer can verify that services billed were actually provided; • a tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals. I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that as part of my care and treatment, it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this Practice’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me. Privacy Rule of Patient Consent Agreement Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a)) I understand that: • I have the right to review this Practice’s Notice of Information practices prior to signing this consent; that this Practice reserves the right to change the notice and practices and that prior to implementation will mail a copy of any notice to the address I’ve provided, if requested; • • I have the right to object to the use of my health information for directory purposes; I have the right to request restrictions as to how my Protected Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that this Practice is not required by law to agree to the restrictions requested; • I may revoke this consent in writing at any time, except to the extent that this Practice has already taken action in reliance thereon.

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the stated categories in this privacy policy exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.

Messaging Terms & Conditions: By opting in, you consent to receive SMS messages from New Patterns of Perception. Depending on your selection, you may receive messages related to:

Message Frequency: Message frequency may vary.

Message and Data Rates: Standard message and data rates may apply, depending on your mobile carrier plan.

Opting Out: You may opt out of receiving SMS messages at any time by replying with “STOP” to any SMS message you receive from us. After you send “STOP,” you will receive a confirmation message, and no further SMS messages will be sent to your number.

Help and Support: For assistance with our SMS service, reply with “HELP” to any SMS message