I authorize my employer and healthcare providers (the “Providers”) participating in the JOYA program to disclose my protected health information, which may include my personal contact information, diagnoses, procedures, treatment, services and products received or purchased from my healthcare provider(s), appointment and payment information (collectively, my “Information”), to JOYA, Inc. (“JOYA”), so that JOYA may use and disclose the Information in order to: (1) perform analytics and deliver portal information on my usage of the JOYA program; (2) evaluate the effectiveness of the JOYA program; (3) perform research activities to enhance the JOYA offering; (4) deliver marketing and promotional communications to me regarding the JOYA products and services; and (5) for other JOYA general business and administrative purposes.

I understand that the Providers may receive remuneration in exchange for the provision of my Information as authorized above, and that once my Information has been disclosed to JOYA, federal privacy law may no longer restrict its use or disclosure and that my Information may be redisclosed to others.

I also understand, however, that JOYA plans to use and disclose my Information only for the purposes described above or as required by law. I understand that my refusal to sign this Authorization will not affect my right to treatment or payment benefits for healthcare.

I also understand that if I sign, I may later withdraw this Authorization by sending written notice of my withdrawal from JOYA to [email protected], and that such withdrawal will not affect any uses and disclosures of my Information prior to the Program’s receipt of the notice.

I am entitled to a copy of this signed Authorization, which expires 10 years from the date it is signed by me or such timeframe as allowed by law.