BY SUBMITTING PAYMENT FOR HEALTH SCREENING SERVICES AND/OR BY SENDING IN MY SAMPLE, I INDICATE THAT I HAVE READ THE CONTENTS OF THIS AUTHORIZATION FOR RELEASE OF PHI AND I HEREBY AUTHORIZE ALL HEALTHCARE PROVIDERS, INCLUDING THEIR DOCTORS, STAFF, AGENTS AND DESIGNEES (“HEALTH CONSULTANTS”), AND THE TESTING LABORATORIES, INCLUDING THEIR DOCTORS, STAFF, AGENTS AND DESIGNEES (“LABS”) THAT PERFORM SERVICES REQUESTED BY OR CONSENTED TO BY ME, WHICH HAVE A RELATIONSHIP WITH MILKXCHANGE, LLC (“COMPANY”), TO USE AND DISCLOSE HEALTH INFORMATION ABOUT ME IN THE MANNER AND FOR THE PURPOSES STATED BELOW.

This authorization applies to the use and disclosure of the following information about me: all information in request(s) submitted by me or for me with my consent and the laboratory test values/results/information which are the result of such request(s).

For avoidance of doubt, I specifically authorize the transfer and release of this information to, between and among myself and the following individuals/organizations and their representatives, affiliates, staff, agents, and designees: (a) Company; (b) your insurance company; (c) any doctor that you designate; (d) applicable Health Consultants and Labs; and (e) other Company partners for the purposes herein and as required or permitted by law.

The information subject to this authorization may be used or disclosed for the following purposes: (a) to facilitate and execute the services requested by me or performed with my consent (including receiving, reviewing, and approving test requests and reviewing, processing, and delivering the test values/results); (b) for treatment, health care operations, and payment services; (c) to conduct statistical research studies using de-identified test results; and (d) as required or permitted under applicable state and federal laws. I may opt to not have my personal information used or disclosed for some of the purposes above. In order to opt-out, I must provide written notice to the Company as set forth below. I understand that such opt-out may affect the services I have voluntarily elected to receive.This authorization is evidence of my informed decision to allow the release of my information to the parties referenced above.

This authorization is effective immediately upon sending in my sample or submitting payment for such services, and will expire ten years after the date of this authorization. Upon my written request, I may inspect or copy the information that I have permitted to be used or disclosed, as permitted by law.

I understand that I have a right to receive a copy of this authorization. I have the right to refuse to agree to this authorization and understand that my refusal may affect the services provided to me. I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and would then no longer be protected by federal privacy regulations.

I may revoke this authorization in writing at any time. I understand that my revocation will not affect any use or disclosure already taken in reliance upon this authorization. My written revocation must be submitted to Company using the contact information below.

To opt not to have your personal information used or disclosed for some of the purposes above, to request written inspection of the information you have permitted to be used or disclosed, or to submit a written revocation of this authorization, contact the Company at: MilkXchange, LLC, 10911 Raven Ridge Road, Ste 103-86, Raleigh, NC 27614; Email: hello@milkxchange.us.

I understand that this authorization may be accepted by someone legally authorized to represent me.

I have read this document carefully, and all my questions were answered to my satisfaction. I hereby consent to participate in this testing program pursuant to the terms, conditions, standards, and requirements set forth herein or as otherwise provided to me.