Expecting Mother’s Information

Upon electronic acknowledgement of this Authorization to Release Protected Health Information (“Authorization”), I hereby authorize Acelleron to disclose my name, phone number, birth date, email address, mailing address, insurance provider, insurance ID and group numbers, insurance policy holder date of birth, provider practice name, breast pump order date, breast pump model name, and baby’s due date (collectively, “my information”) to Nest Collaborative for the purpose of communicating with me about virtual lactation consultations, which I have requested additional information on.

I further acknowledge and understand the following:

Acelleron will not condition treatment or the provision of services to me on providing this Authorization and nothing in this Authorization prevents me from communicating directly with Nest Collaborative regarding my questions.

Information disclosed pursuant to this Authorization may be subject to redisclosure by Nest Collaborative and no longer be protected by federal regulations regarding privacy of health information.

Acelleron receives compensation from Nest Collaborative to provide marketing services related to lactation consultations.

I have the right to revoke this Authorization at any time, except to the extent that Acelleron has taken action in reliance on the Authorization, by delivering or sending written notice of revocation to Acelleron at the following address: 21 High Street, Suite 303, North Andover, MA 01845.

If I do not revoke this authorization, it will expire two years upon acknowledgement of this authorization.