I voluntarily consent to reasonable and necessary evaluation, diagnosis, testing, treatment, medication management, care coordination, referrals, and follow-up services provided by Olive Health advanced practice registered nurses (APRNs) and authorized members of the care team, within their applicable scope of practice. I understand that no result can be guaranteed; I may ask questions, refuse a recommended service, seek a second opinion, or discontinue services at any time. Separate consent may be requested for procedures or services requiring additional authorization. This consentremains effective until revoked in writing, except for care already provided or actions already taken in reliance on it.

I authorize Olive Health to verify benefits, submit claims, and release information reasonably necessary for treatment, payment, and health care operations. I assign directly to Olive Health any insurance benefits payable for covered services. I understand that insurance verification is not a guarantee of payment and that I am responsible for copays, coinsurance, deductibles, noncovered services, and balances not paid by insurance, to the extent permitted by law and applicable contracts. I am responsible for notifiying Olive Health of any changes to coverage prior to appointment visits and understand that failure to do may result in a non covered service.

When telehealth is used, I consent to receiving health care through secure electronic communications. I understand the APRN will identify themself and practice location, use professional judgment consistent with in-person standards, document the encounter, and protect the resulting medical record. Telehealth has limitations, including possible technology failure and the inability to perform a complete hands-on examination. I may decline or stop a telehealth encounter and may be directed to in-person or emergency care when clinically appropriate.

Olive Health may contact me for appointments, care coordination, test results, referrals, medication matters, billing, and other health care communications. I select the methods below and understand that standard text and email may not be encrypted and may be intercepted, misdirected, stored, or accessed by others. I accept these risks, will keep my contact information current, and understand electronic communications are not for emergencies. I may change or withdraw these preferences in writing without affecting prior communications. Message and data rates may apply.

I acknowledge that I received or was offered OliveHealth's current Notice of Privacy Practices, which explains permitted uses and disclosures of my health information, my privacy rights, Olive Health's duties, and how to ask questions or file a complaint. Signing this acknowledgment does not authorize uses or disclosures beyond those permitted by law. If I decline to sign, Olive Health may document its good-faith effort to provide the Notice.

MOBILE PRIMARY CARE - FLORIDA APRN PRACTICE
Records, CareManagement&Medication Information

Expiration

I understand that I may revoke this authorization at any time by written notice to the party authorized to disclose the information, except to the extent action has already been taken in reliance on it. Treatment, payment enrollment, or eligibility for benefits will not be conditioned on signing this authorization unless permitted by law. Information disclosed may be redisclosed by the recipient and may no longer be protected by HIPAA. I am entitled to a copy of this signed authorization.

I consent to CCM services when I am eligible.CCM may include an electronic comprehensive care plan, medication review, health monitoring coordination with specialists and community services, and communication between visits. I understand that (1) only one billing practitioner or practice may furnish and be paid for CCM services during a calendar month; (2) Medicare or my insurance may apply copays, coinsurance, or deductibles; (3) I may stop CCM services at any time, effective at the end of the calendar month after Olive Health receives my request, and (4) Olive Health will document my consent in the medical record and provide access to my care plan as required.

I certify that the information I provided is accurate to the best of my knowledge. I had an opportunity to ask questions, understand that I may request copies of signed forms, and voluntarily agree to the selections and authorizations above.

Practice use: NPP provided electronically NPP provided on paper Patient dedined to acknowledge, good-faith effort documented

Olive Health, LLC | 4912 W Trapnell Rd, Plant City, FL 33566 | (813) 417-4767 | FrontDesk@olivehealthff.com

Page 2

Effective date: August 4, 2026

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THIS NOTICE REMAINS IN EFFECT UNTIL REVISED OR REPLACED BY AN UPDATED NOTICE OF PRIVACY PRACTICES.

• Get an electronic or paper copy of your medical record. We generally will provide a copy or summary within the time required by law and may charge a reasonable, cost-based fee.
• Ask us to correct information you believe is incorrect or incomplete. We may deny the request, but we will explain why in writing.
• Request confidential communications, such as contacting you at a particular phone number, email address, or mailing address.
• Ask us to limit certain uses or disclosures. We are not always required to agree, except for certain disclosures to a health plan when you paid in full out of pocket and the law otherwise permits the restriction.
• Receive an accounting of certain disclosures, obtain a paper copy of this Notice, choose someone legally authorized to act for you, and file acomplaint without retaliation.

For certain information, you may tell us your preferences about sharing with family, friends, caregivers, or others involved in your care or payment. We may share information when needed for disaster relief or to lessen a serious and imminent threat. We will obtain your written authorization for uses and disclosures not otherwise permitted by law, including most marketing uses, sale of health information, and most uses or disclosures of psychotherapy notes. You may revoke an authorization in writing, except to the extent we already acted in reliance on it.

• Treatment provide, coordinate, and manage your care; communicate with pharmacies, laboratories, imaging providers, specialists, facilities, home health agencies, caregivers, and other members of your care team.
• Payment verify coverage, submit claims, obtain prior authorization, collect payment, and coordinate benefits.
• Health care operations: quality improvement, training, credentialing, auditing, compliance, business planning, patient safety, and practice administration.
• Contact you: appointment reminders, follow-up care, test results, preventive care, prescription matters, care management, patient education, and health-related services.
• As permitted or required by law: public health and safety activities; abuse, neglect, or domestic violence reporting; health oversight, judicial or administrative proceedings; law enforcement workers compensation; organ donation; coroners or medical examiners; national security; correctional institutions; and other legallyauthorized purposes.

Some records may receive additional protection under federal or Florida law, including certain substance use disorder, mental health, HIV/AIDS, genetic, and reproductive health information. Olive Health will follow any more protective law that applies. Uses and disclosures of substance use disorder records subject to 42 CFR Part 2 will be handled as required by that law.

• We are required by lawto maintain the privacy and security of protected health information and to provide this Notice.
• We will notify you if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the Notice currently in effect. We may change this Notice and apply the revised Notice to information we already hold and future information. Thecurrent Notice will be available on request and on our website, if maintained.

Olive Health, LLC
4912 W Trapnell Rd, Plant City, FL 33566
Phone: (813) 417-4767 | Email: FrontDesk @olivehealthfl.com

You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Olive Health will not retaliate against you for filing a complaint.

I acknowledge that I received or was offered a copy of Olive Health's Notice of Privacy Practices.

Olive Health, LLC | 4912 W Trapnell Rd, Plant City, FL 33566 | (813) 417-4767 | FrontDesk@olivehealthfl.com