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Please read the following terms carefully as this is a legally binding agreement that affects how Populus Media may use and disclose information about you.

You have requested that Populus Media provide services to you, including matching you with a provider in your area or through a telehealth consult, and a pharmacy to fill any prescriptions issued by such provider (the “Services). Please be advised that Populus Media will still provide the Services to you even if you do not consent to this Authorization.

For purposes of this Authorization, “Customer Data” means information about you that is collected by Populus Media in the course of providing the Services, including information submitted by you to Populus Media in the course of requesting the Services, and any information about your interest in certain medications, your health condition(s), and any prescriptions issued to you by the provider with whom you are matched by Populus Media, including whether such prescriptions were filled or refilled. Some or all of the Customer Data may be individually identifiable information that is subject to protection from disclosure under state or federal law, or may be “Protected Health Information” subject to the protections HIPAA (the Health Insurance Portability and Accountability Act of 1996, as amended) against unauthorized use or disclosure.

For purposes of this Authorization, “Partners” means pharmaceutical companies and marketing agencies with whom Populus Media has a financial relationship.

You acknowledge and give express consent to the following uses and disclosures of “Customer Data”:

(1) Marketing. Populus Media may disclose Customer Data to our Partners or otherwise use Customer Data for marketing and advertising activities, including but not limited to providing you with information about products or services offered by our Partners.

(2) Sale. Populus Media may sell Customer Data to third parties for research, marketing, or any other lawful purpose, in exchange for financial remuneration. You acknowledge and agree that Customer Data used and disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal and/or state law.

You acknowledge that Populus Media may receive financial remuneration from its Partners in connection with the uses and disclosures of Customer Data described above.

You acknowledge that you have the right to revoke this authorization at any time, except to the extent that Customer Data has already been used and disclosed by Populus Health in reliance on this authorization.

You understand that if you wish to revoke this authorization in the future, you must do so in writing by sending a dated and signed letter stating that you revoke this authorization to Populus Health at the following address: Unless revoked by you in writing, this Authorization shall expire twenty (20) years from the date it is signed by you, or sooner if required by applicable state law.

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