Authorization for Laboratory Testing

DRAFT FOR ATTORNEY REVIEW. Original starting draft. Lab-ordering rules vary by state (including who may order tests and direct-to-consumer testing requirements), so counsel must conform this before it goes live in production.

What You Are Authorizing

By signing below, you authorize a licensed Biomarker Health clinician to review your intake and, where clinically appropriate, sign an order for laboratory testing on your behalf — including your founding biomarker panel — and to direct that testing to a certified laboratory. You also authorize the laboratory to perform the ordered tests and to return your results to your clinician and to your Biomarker Health account.

A clinician-patient relationship is established for the purpose of reviewing your intake and ordering and interpreting your labs. Whether any specific test is ordered is determined by the clinician's professional judgment. Submitting an intake or paying a fee does not guarantee that any particular test will be ordered.

How It Works

1. You complete your intake, providing accurate and complete health information.
2. A licensed Biomarker Health clinician reviews your intake and signs the lab order if appropriate.
3. Your sample is collected — on-site at our clinic by a licensed clinician, or at a partner draw location.
4. A certified laboratory analyzes your sample.
5. Results are returned to your clinician and posted to your account, where you can view them.

What the Testing Involves

Most panels require a blood draw. Drawing blood is a routine procedure with minor and uncommon risks, which can include discomfort, bruising, bleeding, lightheadedness, or, rarely, infection at the draw site. Your clinician or the draw staff will discuss any specific risks that apply to you.

How Your Results Are Used

• Results are made available to your treating clinician and to you through your account.
• Lab results are one input into clinical decision-making and must be interpreted by a qualified clinician. Do not self-diagnose or self-treat based on your results.
• Your clinician will use your results, together with your history and goals, to discuss whether any treatment plan is appropriate. Ordering or completing labs does not guarantee any diagnosis, treatment, or prescription.

Sharing of Information

To perform and process your testing, we share necessary information with the laboratory and, if a treatment plan results, potentially with a pharmacy. These parties handle your protected health information consistent with HIPAA and, where applicable, under Business Associate Agreements. Our broader practices are described in our Notice of Privacy Practices and Privacy Policy.

Financial Responsibility

Laboratory fees may be included in your membership price depending on which specific biomarkers you order and which membership level you select. Additional biomarkers beyond what your plan includes may be billed separately. The applicable fees will be disclosed to you before any testing is ordered. The Services are cash-pay and are not billed to insurance.

Your Rights

• You may ask questions about any test before it is ordered or performed.
• You may decline any recommended test.
• You may withdraw this authorization at any time, in writing. Withdrawal does not apply to testing already ordered, performed, or in process.

Consent

I have read and understand this Authorization for Laboratory Testing. I have had the opportunity to ask questions and have them answered.

I authorize a licensed Biomarker Health clinician to order laboratory testing for me, and I authorize the laboratory to perform that testing and return my results to my clinician and to my account.

Patient name: ______________________________

Signature: ______________________________ Date: ____________

(For online enrollment, this authorization may be captured electronically with a date-and-time stamp.)