Surescripts Consent Agreement

I hereby authorize PursueCare (PAI Delaware Holding Company, Inc.) and its affiliated entities to access and obtain my prescription history from Surescripts, a clearinghouse for prescription medication history.

I understand that this information may include details about my current and past prescriptions, including the names of medications, dosages, and dates of fill. I acknowledge that this information may be used by PursueCare and my healthcare providers to provide better care, coordinate my treatment, and avoid any potential medication interactions or complications.

I understand that my prescription information will be kept confidential and will only be accessed by authorized professionals who are involved in my care. I also understand that I have the right to revoke this consent at any time by providing written notice to my healthcare provider.

By signing below, I certify that I have read and understand the terms of this consent form and I freely give my consent to PursueCare and its affiliate entities to access and obtain my prescription history from Surescripts.