I allow the release of any medical information necessary to process this test. I authorize the ordered laboratory test(s The specimen identified on this form is my own. For payment of completed services rendered to my specimen as requested by my physician, I transfer and assign any benefits of insurance to Coast Diagnostics, LLC and authorize claims to be submitted on my behalf directly to my medical insurance. I authorize the lab to release any medical information to resolve claim for payment to all insurance carriers of which I am associated. I understandand acknowledge thatlwill forward anypaymentireceivefrom my insurance carrier/health plans for services rendered by Coast Diagnostics, LLC. In the event that insurance does not pay, I acknowledge that I may be responsible to pay any deductible, co-pays, or co- insurance. If I request more than 1 Covid-19 test I may be responsible for the payment of subsequent tests.

I, hereby authorize Coast Diagnostics to use or disclose my protected health information relating to:

All General Medical:

• Patient information sheets
• Diagnostic test results

I understand that information regarding my protected health information is protected under the privacy provisions of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), and their implementing regulations. See generally 42 C.F.R. Part 2; 45 C.F.R. Parts 160, 164. I understand that my health information specified above will be disclosed pursuant to this authorization, that the recipient of the information may redisclose the information and federal law under HIPAA may no longer protect it. I understand that I may revoke this consent verbally or in writing at any time except to the extent that action has been taken in reliance of it, and that this consent will expire in one (1) year of date of signature. I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to disclosure for other purposes.

I authorize the release of my health information to:

I understand and agree to the following:

Information used or disclosed pursuant to this authorization may be subject to re- disclosure by the recipient and may no longer be protected by federal or state privacy laws. I have a right to change my mind about this authorization and revoke it. I must send my written revocation to the Medical Records Department/Privacy Officer of my Provider/Covered Entity. A revocation is not effective to the extent that the provider has relied on the use or disclosure of the protected health information. I KNOW THAT I DO NOT HAVE TO SIGN THIS FORM. My choice about whether to sign this form will not change the way my health care providers treat me. I may inspect or copy any protected health information to be used or disclosed as allowed on this form. A copy of this form may be treated as a signed original.

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