PLEASE READ THIS AUTHORIZATION CAREFULLY. BY SIGNING OR ELECTRONICALLY ACCEPTING THIS AUTHORIZATION, YOU ARE GIVING YOUR CONSENT FOR EVOLVE YOUR BOD AND ITS AFFILIATED ENTITIES TO USE AND SHARE YOUR PROTECTED HEALTH INFORMATION AS DESCRIBED BELOW.

I. Purpose of This Authorization

This Authorization for Use and Disclosure of Protected Health Information (“Authorization”) is required for you to receive healthcare services coordinated through the Evolve Your Bod platform. It provides your explicit, informed consent for Evolve Your Bod (AA Health Solutions, LLC) to collect, use, store, transmit, and share your Protected Health Information (“PHI”) and personal health data with the entities identified in this document for the purposes of treatment, care coordination, payment, and healthcare operations.

This Authorization applies to all care models available through Evolve Your Bod, including Telehealth (“TH”), In-Person Visits (“IPV”), Hybrid Consult + IV Therapy (“Hybrid”), and Mobile IV Therapy (“Mobile IV”). The specific entities involved in your care may vary depending on your care model.

This Authorization supplements, but does not replace, the Evolve Your Bod Terms of Service, Privacy Policy, and Notice of Privacy Practices.

II. Information Covered by This Authorization

This Authorization covers the following categories of information, collectively referred to as your “Health Information”:

A. Protected Health Information (PHI)

– Medical history, current health conditions, diagnoses, and treatment records.

– Medications, prescriptions, and pharmaceutical records (including compounded medications).

– Laboratory results, diagnostic test results, and imaging reports.

– IV therapy records, including formulations administered, vitals recorded during treatment, and adverse event documentation.

– Clinical notes, treatment plans, and provider communications.

– Telehealth encounter records, including audio, video, and messaging communications.

– Vital signs, biometric data, and physical examination findings collected by on-site clinical staff.

B. Personal Identifying Information

– Full name, date of birth, gender, and contact information (address, phone, email).

– Social Security number (if required for insurance billing or identity verification).

– Insurance information, including plan details, member ID, and group number (for IPV, Hybrid, and Mobile IV services where insurance applies).

– Payment and billing information.

– Emergency contact information.

– Photograph or government-issued identification (if required for identity verification).

C. Intake and Questionnaire Data

– Health intake questionnaires and screening responses submitted through the Evolve Platform.

– Lifestyle, dietary, exercise, and wellness information provided during intake.

– Allergy, medication, and medical history disclosures.

III. Entities Authorized to Receive Your Health Information

By signing this Authorization, you consent to the disclosure of your Health Information to the following categories of entities. The specific entities involved will depend on your care model.

Evolve Your Bod may also share your Health Information with additional entities not listed above when required by law, court order, or regulatory authority, or when necessary to prevent a serious threat to your health or safety or the health or safety of others.

IV. Purposes for Which Your Information May Be Used and Disclosed

Your Health Information may be used and disclosed for the following purposes:

A. Treatment and Care Coordination

– To coordinate your care across the Evolve platform and its affiliated providers, clinics, and clinical staff.

– To share intake data, medical history, and clinical records with the rendering provider or Medical Group responsible for your care.

– To transmit physician orders, including IV therapy orders, to on-site nurses or mobile field nurses for administration.

– To facilitate referrals to specialists, partner clinics, or other healthcare resources when clinically appropriate.

– To communicate treatment plans, follow-up instructions, and clinical updates between providers involved in your care.

B. Payment and Insurance

– To process payments for services rendered through the Evolve Platform.

– For IPV, Hybrid, and Mobile IV services: to verify insurance eligibility, submit claims, process pre-authorizations, and coordinate benefits with your insurance carrier or payer. Insurance billing may be performed by the rendering provider, the partner clinic, or by Evolve Your Bod acting as a billing agent on behalf of the rendering provider, depending on the arrangement in place for your specific care model.

– For Telehealth services: to process cash-pay transactions. Insurance is not accepted for telehealth-only services.

C. Healthcare Operations

– To conduct quality assurance, clinical audits, and performance improvement activities.

– To maintain and improve the Evolve Platform’s technology, security, and service delivery.

– To comply with accreditation, licensure, and certification requirements.

– To fulfill reporting obligations under applicable federal, state, and local laws and regulations.

D. Legal and Regulatory Compliance

– To comply with applicable federal and state laws, including HIPAA, the Texas Medical Practice Act, and Texas Health and Safety Code requirements.

– To respond to lawful requests from regulatory agencies, courts, and law enforcement.

– To report adverse events, public health concerns, or suspected abuse as required by law.

V. How Your Information Flows by Care Model

The following describes the typical data flow for each care model. Understanding this flow is an important part of your informed consent.

Telehealth (TH)

You complete intake on the Evolve Platform → Your intake data and health information are securely transmitted to the affiliated Medical Group and assigned provider → The provider conducts your telehealth consultation and makes clinical decisions → If a prescription is issued, your information is transmitted to a licensed pharmacy for fulfillment → If lab work is ordered, relevant information is transmitted to the laboratory.

In-Person Visit (IPV)

You complete intake on the Evolve Platform → Your intake data is shared with the partner clinic (e.g., ProMed) where your appointment is scheduled → The partner clinic receives your data for the purpose of preparing for your visit and rendering care → You may sign additional clinic-specific consent forms at the partner clinic → The clinic renders care, documents the encounter, and handles insurance billing if applicable → Prescriptions and lab orders follow the same flow as TH.

Hybrid (Consult + IV Therapy)

You complete intake on the Evolve Platform → Your intake data is shared with Evolve, the satellite/facilitating site, and the rendering Medical Group (e.g., ProMed) → On-site clinical staff (e.g., registered nurse) collects vitals and facilitates the encounter → The remote physician conducts the telehealth evaluation and issues treatment orders, including IV therapy orders → The on-site nurse administers IV therapy under the physician’s order → Encounter records, vitals, and IV therapy documentation are shared among Evolve, the satellite site, and the Medical Group → Insurance billing is handled by the rendering provider or partner clinic.

Mobile IV Therapy

You complete intake on the Evolve Platform → Your intake data is shared with Evolve and the rendering Medical Group → A licensed physician reviews your information and issues an IV therapy order → A licensed nurse travels to your designated location and verifies your identity and health status → The nurse administers IV therapy under the physician’s order → Encounter records, vitals, and IV documentation are transmitted securely back to Evolve and the Medical Group → Insurance billing is handled by the rendering provider.

VI. Your Rights Regarding This Authorization

A. Right to Revoke

You have the right to revoke (cancel) this Authorization at any time by submitting a written request to Evolve Your Bod at info@evolveyourbod.com with the subject line “Revocation of PHI Authorization.” Your revocation will take effect upon receipt, except to the extent that Evolve Your Bod or its affiliated entities have already taken action in reliance on this Authorization prior to receiving your revocation. Revoking this Authorization may limit or prevent your ability to continue receiving healthcare services through the Evolve Platform.

B. Right to Refuse

You have the right to refuse to sign this Authorization. However, because this Authorization is necessary for Evolve Your Bod to coordinate your care across its affiliated providers, clinics, pharmacies, and clinical staff, refusing to sign may prevent you from receiving healthcare services through the Evolve Platform. Your refusal to sign this Authorization will not affect your ability to receive healthcare services from other providers outside of the Evolve Platform.

C. Right to Inspect and Copy

You have the right to receive a copy of this Authorization after you have signed it. You also have the right to inspect and obtain copies of your Health Information that has been disclosed pursuant to this Authorization, subject to applicable law.

D. Right to an Accounting of Disclosures

You have the right to request an accounting of certain disclosures of your PHI made pursuant to this Authorization, as provided under HIPAA and applicable state law. To request an accounting, contact Evolve Your Bod at info@evolveyourbod.com with the subject line “Accounting of Disclosures.”

E. No Conditioning of Treatment

Evolve Your Bod will not condition your treatment on whether you sign this Authorization, except to the extent that the Authorization is necessary for Evolve to coordinate the specific services you are requesting. If the services you are requesting require data sharing with affiliated entities (which is the case for all Evolve care models), this Authorization is a necessary part of the care coordination process.

VII. Re-Disclosure Notice

Once your Health Information has been disclosed pursuant to this Authorization, the information may no longer be protected by HIPAA if the recipient is not a covered entity or business associate under HIPAA. However, recipients who are covered entities or business associates remain bound by HIPAA and their own privacy policies. Evolve Your Bod requires all affiliated entities to maintain appropriate safeguards for your Health Information through contractual agreements, including Business Associate Agreements where applicable.

Your Health Information will not be sold by Evolve Your Bod for marketing purposes or any other commercial purpose without your separate, specific written authorization.

VIII. Duration and Expiration

This Authorization will remain in effect for as long as you maintain an active account with Evolve Your Bod and continue to receive or be eligible to receive healthcare services through the Evolve Platform, unless you revoke it in writing as described in Section VI above.

Upon revocation or account termination, Evolve Your Bod will cease making new disclosures of your Health Information under this Authorization, except as required by law or to the extent that disclosures have already been initiated. Evolve Your Bod will retain your Health Information in accordance with its data retention policies, applicable medical record retention laws, and any regulatory requirements.

IX. How We Protect Your Information

Evolve Your Bod implements industry-standard security measures to protect your Health Information, including:

– Encryption of data in transit and at rest.

– HIPAA-compliant telehealth platform and data storage infrastructure.

– Role-based access controls limiting who can view your Health Information to those with a legitimate need to know.

– Business Associate Agreements (BAAs) with vendors and technology partners that handle PHI.

– Audit logging to track access to your Health Information.

– Staff training on HIPAA, privacy, and data security protocols.

While we implement rigorous safeguards, no system can guarantee absolute security. You are encouraged to report any suspected unauthorized access to your information immediately by contacting info@evolveyourbod.com.

X. State-Specific Disclosures

Texas

This Authorization is provided in compliance with the Texas Medical Records Privacy Act (Texas Health & Safety Code Chapter 181) and the Texas Medical Practice Act. Under Texas law, your health information is confidential and may only be disclosed as authorized by you or as permitted by law. You have the right to file a complaint with the Texas Attorney General or the U.S. Department of Health and Human Services if you believe your privacy rights have been violated.

California

If you are a California resident, you have additional rights under the Confidentiality of Medical Information Act (CMIA) and the California Consumer Privacy Act (CCPA/CPRA). Health information governed by HIPAA is exempt from CCPA, but non-medical personal information may be subject to California privacy law. For more information, please refer to our California Privacy Notice at evolveyourbod.com/california-consumer-privacy-act-ccpa-privacy-notice.

Other States

If you reside in a state with additional health information privacy protections, those protections apply in addition to this Authorization. Evolve Your Bod will comply with the more protective standard where state and federal law differ.

XI. Questions and Contact Information

If you have any questions about this Authorization, how your Health Information is used and shared, or how to exercise your rights, please contact:

Evolve Your Bod — Privacy Office

AA Health Solutions, LLC

5521 Bellaire Drive South, Suite 200

Fort Worth, TX 76109

Email: info@evolveyourbod.com (Subject: Privacy Office)

Phone: 866-301-3141

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint.

XII. Patient Acknowledgment and Consent

By signing below, electronically accepting this Authorization through the Evolve Your Bod platform, clicking ‘I Agree,’ checking the associated consent box, or continuing to use Evolve Your Bod services after being presented with this Authorization, I acknowledge that:

– I have read and understand this Authorization for Use and Disclosure of Protected Health Information.

– I understand the types of information that may be used and disclosed, the entities that may receive my information, and the purposes for which my information may be shared.

– I understand how my data flows through each care model (Telehealth, In-Person Visit, Hybrid, and Mobile IV) as described in Section V.

– I understand that I have the right to revoke this Authorization at any time by submitting a written request, and that revocation may affect my ability to receive services through the Evolve Platform.

– I understand that I have the right to refuse to sign this Authorization, but that refusal may prevent me from receiving healthcare services through Evolve Your Bod.

– I understand that once my information has been disclosed to a recipient that is not a HIPAA-covered entity, it may no longer be protected by HIPAA.

– I have been offered a copy of this Authorization for my records.

– I am signing this Authorization voluntarily and not under coercion or duress.

If this Authorization is signed by a personal representative on behalf of the patient, please also provide: