Authorization for Use and Disclosure .

I authorize Xact Rx, LLC to use and disclose my protected health information (PHI), including information related to my prescriptions, medical condition, and treatment, for the purposes of:

·  Requesting prescription authorizations from my healthcare provider(s),

·  Communicating with my provider(s) about my compounded medication needs,

·  Filling and processing my prescriptions through this pharmacy.

I understand that:

·  My PHI may be shared electronically, including via secure email or other HIPAA-compliant platforms.

·  This authorization is voluntary and may be revoked at any time by submitting a written request to Xact Rx, LLC, except to the extent that actions have already been taken based on this authorization.

·  Revocation of this authorization will not affect my ability to receive treatment, obtain payment, or my eligibility for benefits.

·  This authorization will remain in effect until revoked by me in writing.

I acknowledge that I have reviewed and understand Xact Rx, LLC’s Privacy Policy and how my health information will be used and protected in accordance with HIPAA and applicable laws.