I authorize Neuronetics to use or disclose Protected Health Information (“PHI”) as defined under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), of the Patient identified above, to Neuronetics for evaluating my candidacy for certain non-invasive mental health treatment options. More specifically, I understand that my treating health care provider has recommended, and I have agreed to, the use of the Neuronetics screening application, NeuroStar PHQ-10 Patient Survey, which follows Patient Health Questionnaire (PHQ)-10, a standardized screening tool for major depressive disorder (MDD). I authorize the release of my PHQ-10 score and responses to the PHQ-10 tool, along with limited demographic information about me, to Neuronetics for purposes of evaluating potential treatment options. I understand that the information released or disclosed pursuant to this authorization may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), alcohol and drug abuse, and mental health treatment and I authorize such disclosure for the purposes stated herein. This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records under 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived. I understand and further authorize Neuronetics to share my results with my treating healthcare provider and to incorporate my results into my electronic medical record maintained by or on behalf of my treating healthcare provider.

I understand that this authorization is voluntary and that I may refuse to sign. I further understand that my treating health care provider may not condition my treatment or eligibility for benefits on completion of this authorization.

I understand that this authorization is in effect for one (1) year or until I revoke this authorization. I understand that I may cancel or revoke my authorization at any time by writing to: customersupport@neurostar.com or 3222 Phoenixville Pike, Malvern, PA 19355. Revocation will be effective immediately upon receipt by Neuronetics, except to the extent that information was previously disclosed in reliance upon this authorization. If my PHI has already been shared, it may not be possible to recall it. I understand that if the person or entity receiving this information is not a health care provider or health plan covered under HIPAA or other federal privacy regulations, the information described in this authorization may be disclosed to other individuals or institutions and no longer protected by these regulations.

I have read this form and agree to the uses and disclosures of the PHI as described. I understand that refusing to sign this form does not stop disclosure of PHI that is otherwise permitted by law without my specific authorization or permission. By signing this authorization, I acknowledge that I have read the authorization and fully understand the terms contained herein. I understand that Neuronetics will provide me with a copy of this signed authorization.

I represent and warrant that: (a) I am the parent or legal guardian of the minor named above; (b) no court has issued any order, judgment, or decree granting custody of the minor to anyone else or otherwise affecting my rights as parent or legal guardian: (c) the minor has not been emancipated; (d) I have the legal right, power, and authority to consent to this Agreement on behalf of the minor and myself; and (e) I am at least eighteen years of age. I have read, and I understand, this Agreement in its entirety. By signing below, I hereby consent to and approve in all respects the terms and conditions of this Agreement and the minor’s execution of this Agreement and agree that both the minor and I shall be bound by all of its terms and conditions. I understand that this consent and approval is not revocable. I agree to defend, indemnify, and hold harmless Neuronetics from and against all Claims by third parties resulting from my or the minor’s breach or alleged breach of this Agreement or any of the representations and warranties contained herein.