Health Information Release

I authorize inHealth to disclose the health information I provide to inHealth to Gelesis, Inc., 500 Boylston Street, Suite 1600 Boston, Massachusetts 02116, and/or its mail order and third party data analytics providers (collectively “Gelesis”).

I am providing this authorization to allow Gelesis to use my information to evaluate and improve the health coaching I receive from inHealth, to send me more customized marketing and educational information related to Plenity and my weight journey, and to evaluate my experiences with Plenity. I understand that any information shared with Gelesis based on this authorization may no longer be protected by federal and state laws that protect health information.

This authorization shall remain valid as long as I continue receiving health coaching from inHealth or I continue filling my Plenity prescription. I understand, however, that I may revoke this authorization in writing at any time by providing notice to inHealth at [insert means of contact]. I understand that revoking my authorization will not impact any disclosures made based on this authorization before my revocation is received and processed. That said, Gelesis understands and respects your privacy, and will use its reasonable efforts to maintain the confidentiality of the information that you provide.

I understand that I am not required to provide this authorization in order to receive health coaching from inHealth, as a condition for payment, enrollment, or eligibility for benefits, or to participate in the Plenity Experience.