I hereby consent to Gather Lab, LLC performing the designated test(s) on the DNA sample provided by me. My signature below constitutes my acknowledgment that I have been informed, by a physician or other licensed practitioner, of the benefits and limitations of this testing. I also consent to Gather Lab, LLC - or its reference lab - to providing de-identified information of a statistical nature to accrediting agencies and Gather Lab, LLC reserves the right to use such anonymous information in compliance with applicable regulations. Assignment of Benefits: I hereby authorize Gather Lab, LLC or its affiliate to bill my insurance company and receive payment from them on my behalf. I acknowledge, however, that I am responsible for payment of my account and any and all charges associated with its collection. I hereby authorize my insurance company to pay the company directly for services rendered. Appeal Authorization: In the event of an underpayment or denial by my insurance carrier, I hereby authorize the company or their designee, to appeal my health plan on my behalf to provide the actions and information necessary to overturn the denial or receive reimbursement for the underpaid claim including any rights to penalties and attorney’s fees provided under LRS §22:1821(A) and other state laws as may be applicable. This authorization shall remain valid until the charges for the orders on this form are paid in full. Donor Signature: I certify that I provided my specimen to the specimen coordinator, that I have not adulterated it in any manner, each specimen used was sealed in my presence, and that the information provided on this form and on the label affixed to each specimen is correct. I authorize the release of the results to the ordering clinician, authorized client/representative, or prescribing/attending physician. I authorize Gather Lab, LLC or its affiliates to release any information required for billing purposes. I acknowledge Gather Lab, LLC or its affiliates may be an out of network provider with my insurer. I agree that if my insurance provider sends payment directly to me, I will endorse the insurance check and forward to Gather Lab, LLC within 30 days.