Novellia was created to bridge the gap between individuals’ complete health story and data currently accessible to clinicians and researchers. As part of this, Novellia offers individuals the opportunity to assist in closing this gap by contributing to research and fostering the development and advancement of clinical breakthroughs. Novellia’s client network includes entities, such as life sciences organizations, that seek to transform the health care industry through their research activities. Such entities seek to accelerate the path to life-changing medicines by utilizing longitudinal data that tracks specific patient journeys in connection with their research. I hereby authorize the use, disclosure, and sale of my Protected Health Information as described below to Novellia, Inc. (“Novellia”) for a period of 24 months from the date I sign this authorization. I understand that this authorization is voluntary, revokable, and that I may refuse to sign this authorization. My failure to sign this authorization or the revocation of this authorization may prevent me from receiving services from Novellia, but will not otherwise affect any treatment, payment, eligibility for benefits or enrollment activities which I am entitled to receive or in which I am entitled to participate.

“Protected Health Information” referred to in this authorization means Protected Health Information as that term is defined under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). HIPAA defines “Protected Health Information” as identifiable information held by a covered entity relating to (a) my past and present physical or mental health or condition; (b) the provision of health care to me; and (c) payment for the provision of health care to me. Protected Health Information may include information that is created both before and after the date of this authorization.

“Protected Health Information” referred to in this authorization means Protected Health Information as that term is defined under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). HIPAA defines “Protected Health Information” as identifiable information held by a covered entity relating to (a) my past and present physical or mental health or condition; (b) the provision of health care to me; and (c) payment for the provision of health care to me. Protected Health Information may include information that is created both before and after the date of this authorization.

This form authorizes the release of all Protected Health Information to Novellia, including the following sensitive health information unless you inform us otherwise: (a) alcohol/drug abuse treatment (other than Part 2 records), (b) HIV/AIDS-related treatment, (c) sexually transmitted diseases treatment, and (d) mental health treatment. To the extent applicable, I authorize Novellia to obtain my Protected Health Information from my health care providers and/or my health insurance plan, either directly or indirectly through a third-party (such as a healthcare clearinghouse or health information exchange platform) or other Novellia designee. I further authorize Novellia to use and disclose all, or any part of, my Protected Health Information, to Novellia’s client network for the clients’ research, evaluation, analysis, or treatment activities, including but not limited to: (i) evaluating the safety and efficacy of therapeutics, (ii) evaluating the cost of care for specific populations, (iii) tailoring care management to improve patient outcomes, (iv) advancing personalized medicine and precision therapeutics, and (v) conducting other research activities that are otherwise deemed appropriate by Novellia’s client network and permitted by applicable law.

I further understand that Novellia’s client network will compensate Novellia in exchange for the collection and access to my Protected Health Information and I authorize such sale of my Protected Health Information.

I understand my Protected Health Information once disclosed may be re-disclosed by the recipient and this re-disclosure may no longer be protected by federal and state law, unless prohibited by certain more restrictive law, and with certain limited exceptions. If I am a resident of California, any person or entity to whom my Protected Health Information is disclosed pursuant to this authorization may not further use or disclose the Protected Health Information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by applicable law.

I understand that I may revoke my authorization at any time by sending written notice to Novellia at support@novellia.com. I understand that my revocation will be effective upon receipt and Novellia will cease the collection of your Protected Health Information, except to the extent that any party has acted in reliance on this authorization.

I acknowledge that I have read and understand this authorization. I understand that I have a right to receive a copy of this authorization. I acknowledge that my authorization will remain valid for a period of 24 months unless earlier revoked by me or as otherwise limited by applicable law. By signing this authorization, I affirm that I am at least 18 years of age and have the legal capacity to provide effective consent.