Discovery takes all reasonable steps to protect personal information and maintain confidentiality. By signing below, I give Discovery Health (Pty) Ltd and my medical scheme, being a medical scheme administered by Discovery Health (Pty) Ltd (“Scheme”), permission to release my Electronic Health Record (EHR) to my healthcare provider. This includes details about chronic condition(s), benefit plan details, certain biographical data and pathology and radiology results. This may include information related to HIV/Aids. I understand that once Discovery Health (Pty) Ltd and the Scheme have handed my records to the healthcare provider, they have no further control over this information and that they will not be accountable for the safeguarding of this information. I do understand that the healthcare provider has confirmed to Discovery Health (Pty) Ltd that he/she will treat my health records as confidential and in line with the relevant legislation. I agree that by making this information available, Discovery Health (Pty) Ltd and the Scheme are not responsible for any loss (whether direct or indirect) that may arise from the use of this information. I agree that I may not hold Discovery Health (Pty) Ltd or the Scheme responsible for any loss that may result from the incorrect use or disclosure of the information by my healthcare provider. Chronic Illness Application I give permission for my doctor to provide Discovery Health with my diagnosis and other relevant clinical information required to review my application for the Chronic Illness Benefit. I understand that: 1.Funding from the Chronic Illness Benefit is subject to meeting benefit entry requirements as determined by Discovery Health. 2.The Chronic Illness Benefit provides cover for disease-modifying therapy only, which means that not all medicines for a listed condition are automatically covered by the Chronic Illness Benefit. 3.By registering for the Chronic Illness Benefit, I agree that my condition may be subject to disease management interventions and periodic review and that this require affording both Discovery Health and my provider with access to my medical records. I understand that if I do not allow Discovery Health or my provider with access, the benefit may be withdrawn. 4.Funding for medicine from the Chronic Illness Benefit will only be provided from when Discovery Health receives an application form that is completed in full. 5.I may need to send an updated or new application form, if the Chronic Illness Benefit department asks for this. I consent to Discovery Health disclosing, from time to time, information supplied to Discovery Health (including general or medical information that is relevant to my application) to my healthcare provider, to administer my Chronic Illness Benefit. I may choose to change or revoke my consent at any time at which time my health information may not be disclosed to my healthcare provider any longer. I will inform Discovery Health of this change or revocation in writing. The results displayed will reflect the change or removal of my consent. Should consent be entirely withdrawn all results will be removed from the display. I accept that those results can be used for bulk statistical analysis. Consent is valid from the date and time of my signature and will continue until such time as consent is removed or changed.