Consent to Treatment I authorize the medical staff, other personnel, and associated health care providers of Mira Mace Medical Group PA (”Mira Mace”) to provide care, including telehealth and related services, as Solace’s staff finds necessary or advisable in my care. If I am making this authorization on behalf of another person, I acknowledge that I am consenting on behalf of the patient and I am authorized to do so. Solace provides care coordination and support through Community Health Integration (CHI), Chronic Care Management (CCM), Principal Illness Navigation (PIN), and Behavioral Health Integration (BHI) programs. These services help manage ongoing or complex conditions, coordinate with my existing doctors, and offer continued support between visits. I understand that:

• Only one provider or organization may bill Medicare (or my insurance) for these services per month.
• Depending on my insurance, I may have a copay or cost share.
• I may stop these services at any time, effective at the end of the calendar month.
• This consent remains in effect unless I revoke it.

Consent to Health Records Requests I authorize Mira Mace’s medical staff and associated providers to request, receive, and use my medical records as needed to coordinate my care. My records will be handled in compliance with HIPAA and applicable privacy laws. Use of Technology and Recordings I understand that Mira Mace may use HIPAA-compliant technology to document visits, including audio or video recordings and AI-assisted transcription tools. These tools are used only for secure note-taking and quality assurance — never to make clinical decisions or share my information outside my care team. Digital Copy I agree that an electronic record of this consent has the same legal effect as a signed paper copy.