HENYIDA LLC Patient Consent & Authorization

Essential Medicine Access Program

1. Purpose of Authorization

I understand that I am requesting assistance from HENYIDA LLC ("HENYIDA") in assessing and coordinating access to a prescribed medicine. I understand that this process may involve communication with my treating healthcare professional, pharmaceutical manufacturers, authorized suppliers, importers, pharmacies, regulatory authorities, and other parties reasonably necessary to evaluate or facilitate my request. I authorize HENYIDA to undertake the activities described below, subject to applicable laws, professional responsibilities, and confidentiality requirements.

2. Authorization to Collect and Process Information

I authorize HENYIDA to collect, receive, securely store, review, and process personal and health information reasonably necessary to evaluate and coordinate my Essential Medicine Access request. This may include:

·       Personal identification and contact information

·       Prescriptions and medicine information

·       Relevant clinical information and medical necessity documentation

·       Treating healthcare professional information

·       Regulatory and import documentation

·       Communications and records relating to my request

I understand that HENYIDA will seek to limit information collection to what is necessary for the requested service.

3. Authorization to Communicate With My Treating Healthcare Professional

I authorize HENYIDA to contact the treating healthcare professional identified in my application for purposes directly related to my medicine access request. These communications may include verifying my prescription, confirming treatment requirements, requesting medical necessity documentation, and clarifying information necessary for regulatory or supply arrangements. I understand that my healthcare professional may require a separate authorization before releasing medical records or other confidential clinical information to HENYIDA.

4. Authorization for Necessary Information Sharing

I authorize HENYIDA to disclose relevant information to appropriate parties involved in evaluating or coordinating my request, including:

·       Treating healthcare professionals and authorized healthcare institutions

·       Pharmaceutical manufacturers and authorized suppliers

·       Licensed importers, distributors, logistics providers, and dispensing pharmacies

·       Competent national or regional regulatory authorities

·       Authorized service providers supporting secure information processing and case administration

I understand that information shared will be limited to what is reasonably necessary for each party's role, except where broader disclosure is required by law or separately authorized. Where possible, manufacturers and commercial suppliers will receive product and procurement information without unnecessary disclosure of my identifiable clinical information.

5. International Processing and Transfers

I understand that my request may involve organizations and service providers located outside my country of residence or treatment. I authorize international sharing of relevant information for the purposes described in this document, subject to applicable privacy requirements and any additional country-specific authorizations required by law. I understand that privacy protections may differ between jurisdictions and that HENYIDA will apply appropriate safeguards to transfers within its responsibility.

6. Understanding the Nature of the Service

I acknowledge that:

·       HENYIDA is facilitating an access and coordination service and is not acting as my prescribing healthcare professional.

·       My treating healthcare professional remains responsible for clinical decisions concerning my treatment.

·       Submission of a request does not guarantee medicine availability, regulatory authorization, import approval, or delivery.

·       Any medicine importation or supply must comply with the applicable requirements of the relevant jurisdiction.

·       HENYIDA may require additional information before determining whether it can proceed with my request.

7. Voluntary Participation and Withdrawal

I understand that my participation in the Essential Medicine Access Program is voluntary. I may withdraw this authorization by submitting a written request to HENYIDA at info@henyida.io. Withdrawal will apply prospectively, subject to applicable law, and will not necessarily reverse information disclosures or actions already lawfully completed in reliance on this authorization. I understand that withdrawal may prevent HENYIDA from continuing the requested service.

8. Duration of Authorization

This authorization remains effective for the duration of my Essential Medicine Access request and associated administrative closure, unless I withdraw it earlier or applicable law requires a different period. For disclosures subject to HIPAA authorization requirements, any applicable expiration date or event must be specified separately and comply with those requirements.

9. Declaration and Agreement

By electronically accepting this authorization, I confirm that:

·       I am the patient identified in the application or am legally authorized to act on the patient's behalf.

·       I have had the opportunity to read HENYIDA's Privacy Notice.

·       I understand the purposes for which my information may be collected, processed, and shared.

·       I understand that my participation is voluntary and that I may withdraw my authorization subject to applicable limitations.

·       The information submitted is accurate to the best of my knowledge.

·       I authorize HENYIDA to proceed with the activities described above.