Premier Health and Wellness Clinic is a participant in the Mississippi Medical Cannabis Program.Program participation by our patients and clinic will be regulated and guided by the Mississippi Medical Cannabis Act. Our goal is to provide a safe and accessible medical cannabis program for all who qualify.

2. Must consent to medical records requests for primary care or specialists to include records over the 6months to 2 years for medical conditions to be confirmed. The providers of Premier Health andWellness Clinic may deem to ask for medical records over a shorter or longer period to ensure patientsafety as well as develop an accurate knowledge base of your health status and diagnoses.

3. Each participant must complete a urine drug screen. Results will be discussed with you, kept confidential, and be used as needed. Despite currently being illegal, a positive result for THC will NOT exclude from medical cannabis program participation. A positive result for other illicit drugs or for prescription medications that are not clinically indicated based on your medical history or known prescription history may exclude participation. These include but are not limited to cocaine, methamphetamines, benzodiazepines, methadone, barbiturates, Phencyclidine (PCP), oxycodone. This will be at the discretion of the certifying provider.

4. Must submit photo ID/license.

5. Must understand that if I am a truck operator or U.S. Dept. of Transportation clearance is required then I am NOT ELIGIBLE regardless of qualifying condition.

6. I agree to the terms of this contract between myself, the patient/medical cannabis cardholder, and Premier Health and Wellness Clinic. I agree to be honest regarding my past and present medical history and consent to releasing medical records as necessary.

I understand that my express consent is required for obtaining and releasing protected health information. This may include testing, diagnosis, and treatment of psychiatric/mental illness, HIV/ AIDS, sexually transmitted infections, drug and/or alcohol use/abuse unless I specify otherwise. I understand that I am not obligated to sign this release to receive treatment, for payment, or for enrollment. I further understand that I can choose to exclude certain information/records, set a time frame for this release to expire or revoke this release at any time in writing by contacting the provider/facility listed above prior to that entity releasing the requested records. In the event that I have chosen to do so and once said released records have been sent to the noted receiving facility, that information may be redisclosed as necessary for care and management purposes and may no longer be protected under privacy law.

YOU ARE ENTITLED TO A SIGNED COPY OF THIS RELEASE

Premier Health and Wellness Clinic creates a record of the care and services you receive from us. We call this record your health information. We required by the federal law to keep your health information private. We are also required to provide you with this Notice so that you will know how we use and disclose your health information and how you can get access to this information. This Notice also lists the rights you have regarding your health information. We will abide by the terms of the Notice. We reserve the right to change the terms of this notice and our privacy practices at any time. Any changes will apply to the health information we already have. When we make changes to our privacy practices, we will post an updated Notice in the clinic. You may request a copy of this notice at any time, and you may view a copy of the Notice on our website or print for your records.

1. Treatment. We may use or disclose your health information to doctors, nurses, technicians, medical students, students in other health care fields, or other personnel who are involved intaking care of you. Additionally, we will/may contact you to (l) remind you of your appointment by calling, e-mailing, texting, or mailing a postcard, or through the patient portal; or (2) discuss treatment alternatives or other health related benefits that may be of interest to you as a patient.

• Payment. We may use or disclose your health information to bill and receive payment for services you receive.• Health Care Operations. We may use and disclose your health information to conduct activities that are called healthcare operations. For example, Premier Health and Wellness Clinic ,personnel or others that perform services may review your health information to assure the quality and appropriateness of the care you receive.• Health Information Exchanges. We may make your health information available electronically to other healthcare providers or other healthcare entities for treatment, health care operations such as for referrals.• Emergencies. We may use or disclose your health information in an emergency treatment situation.• Food and Drug Administration. We may use and disclose your health information to a person or company required by the Food and Drug Administration to track adverse events and as otherwise required.• Workman's Compensation. We may use and disclose your health inf01mation as necessary to comply with workman's compensation laws and other similar legally- established programs.• Federal, State or Local Law. We may use and disclose your health information when required bylaw.• Government Agencies and Law Enforcement. We may use or share your health information to government agencies for law enforcement purposes or with a law enforcement official.

 •Order by a Court, Tribunal or Other Judicial Proceeding. We may disclose your health  information when ordered by a court, tribunal, or other judicial proceeding, or in response to a  subpoena.  •  Public Health Reasons. We may use or disclose yow- health information for public health  •  reasons. For example, we can share health information about you for certain situations such as:  preventing disease; helping with product recalls; reporting adverse reactions to medications;  reporting suspected abuse, neglect, or domestic violence; or preventing or reducing a serious  threat to yours or anyone's health or safety, such as instances of child and/or elderly abuse or  neglect.  Coroners, Medical Examiners and Funeral Home Directors. We may disclose your health  information to a coroner, medical examiner, or funeral home director  •  Specialized Government Functions. We may disclose the health information of military  personnel and veterans in certain situations to the government. We may also disclose your  health information for national security reasons  •  Treatment alternatives. We may use and disclose your health information to manage and  coordinate your healthcare and inform you of treatment alternatives and other health related  benefits that may be of interest to you. This may include telling you about treatments, services,  products, and/or other healthcare providers. For example, if you are diagnosed with diabetes, we  may tell you about nutritional and other counseling services that may be of interest to you.

People Who Help Take Care of You. We may provide your health information to a familymember, friend, or other person, if they help take care of you, or if they are responsible forpaying for your care, unless you tell us not to. In emergencies, you will not be given thechance to tell us not to provide information to those who take care of you.

You have the right to inspect and to get copies of your health information upon written request. You have the right to request a correction to your health information upon written request. If you believe that your health information is incorrect or information is missing, you may request that the information be changed or added. You must make the request in writing. You may be asked for other supporting documents to support those changes. You have the right to choose how we communicate with you and can choose mail, email, text, or patient portal, or combination of any of these.

I acknowledge and hereby authorize Premier Health and Wellness Clinic to use and/or disclose my health information which specifically identifies me, or which can reasonably be used to identify me, to carry out my treatment, to collect payment and perform healthcare operations. Treatment includes but is not limited to: the administration and performance of all treatments, the administration of any needed anesthetics, the administration and use of in office injections, prescribed medications, the performance of such procedures as may be deemed necessary or advisable in my treatment, including but not limited to diagnostic procedures, the taking and utilization of cultures and of other clinically appropriate laboratory tests, all of which in the judgment of the provider or their assigned designees may be considered medically necessary or advisable. I acknowledge and understand that this consent is given in advance of any specific diagnosis or treatment, that these services are voluntary, and that I have the right to refuse these services at anytime. I intend this consent to be continuing in nature even after a specific diagnosis has been made and Treatment recommended. This consent will remain in full effect unless revoked in writing and will not affect any actions that were taken prior to receiving my revocation. A photocopy or electronic copy of this consent shall be considered as a valid original

Risks:• Emails and texts can be circulated, forwarded, stored electronically and on paper, or broadcast to unintended recipients• Email and text senders can misaddress an email or text• Email and texts can be intercepted, altered, forwarded, or used without authorization or detection• Emails and texts may not be secure, and therefore it is possible that the confidentiality of such communications may be breached by a third party. Email and text service providers may have access to your emails or texts Conditions: Premier Health and Wellness is not liable for improper disclosure of confidential info1mation that is not caused by Premier Health and Wellness' misconduct. You must acknowledge and consent to the following conditions:• Email and text are not appropriate, nor should they be used for urgent or emergent situations. Please call 911 in the event of an emergency• Per your request, Premier Health and Wellness Clinic may send emails or texts to you as necessary for your diagnosis, treatment, billing eligibility, and other handling. You should not use email or text for sensitive communications (AIDS/HIV, mental health, developmental disability, or substance abuse).• You are responsible for informing, in writing, if you would like to cease or limit email or text communication with Inspire Health and Wellness. You are responsible for protecting your email and telephone accounts and passwords or any other means of access to each. Premier Health and Wellness Clinic is not liable for breaches on confidentiality involving your email, telephone, or computer that are caused by you or a third party.

If you wish to send and receive emails from Premier Health and Wellness, you should: Limit or avoid use of public computers and networks. Promptly inform Premier Health and Wellness of changes in your email address or telephone number. Before sending emails containing personal information, you should ensure the email is addressed to the correct recipient, use subject line text, put your name in the body of the text,' and take precautions to preserve the confidentiality of your emails or texts. By signing this agreement, you acknowledge that you have received and read the above information. ln addition, you agree to any instructions that Premier Health and Wellness may impose regarding sending and receiving email or text communications containing personal health information.