I certify that I have voluntarily provided a fresh and unadulterated specimen for analytical testing. The information provided on this form and on the label affixed to the specimen is accurate. I hereby authorize BiomeDNA or its assignee to bill any and all insurance/health coverage on my behalf for laboratory services rendered by BiomeDNA. I irrevocably assign to and direct that payment be made to BiomeDNA Inc. I also authorize BiomeDNA to release any information required for billing and reimbursement. I further authorize BiomeDNA to release the results of this testing to the treating authorized healthcare provider or facility. I acknowledge that BiomeDNA may be out-of-network facility/provider with my insurance provider. I am also aware that in some circumstances my insurance provider may send payment directly to me. I agree to endorse the insurance check and forward it to BiomeDNA within 15 days of receipt as payment towards the lab services provided by BiomeDNA. I acknowledge that I am responsible for any amounts not covered by my insurer including any deductibles and co-payments co-insurance. I understand that BiomeDNA may use my specimen and any testing performed on that specimen for research and development so long as the information has been deidentified pursuant to law.                                                                                                                                                              

This specimen was provided voluntarily for analysis and I authorize BiomeDNA to process. The payment is NON-REFUNDABLE.