Patient Certification and Authorization

I certify that the information provided in my Patient Assistance Program Application is true and accurate. I authorize Counsyl or its agents to verify this information to determine my financial need in connection with payment for Counsyl’s services, including requesting additional information or supporting documentation. I understand that any financial assistance may terminate if I have misrepresented any information and that providing this information does not guarantee I will qualify for assistance. I certify that paying for Counsyl’s services would cause me financial hardship.

I authorize Counsyl to use or disclose the information in my application to assess my eligibility for participation in Counsyl’s Patient Assistance Program. I understand that assistance, if any, is temporary and may be modified or discontinued at any time. I understand that I may cancel this authorization at any time by contacting Counsyl at billing@counsyl.com or (888) COUNSYL. Canceling this authorization will prohibit disclosure of my information after my request is received and processed but will not affect prior disclosures. This authorization is effective only through the end of my participation in Counsyl’s Patient Assistance Program or Counsyl’s denial of my application.

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