Financial Assistance Program Application

Attestation

I hereby acknowledge the above information is true and correct. I authorize Ambry Genetics to verify the above information for the sole purpose of assessing financial need, including the right to seek supporting documentation for the above request. I understand that if I do not qualify, I will be notified and Ambry Genetics will bill me. I hereby acknowledge that I am neither related to, nor employed by, the physician who ordered the testing. I understand and agree that Ambry Genetics Corporation reserves the right at any time and without notice to modify the application form; to modify or terminate this program; and to audit the information I have provided on this application. I further certify and agree that I will not seek reimbursement or credit for this testing from any insurer, health maintenance organization, government program or other source of financial assistance.

Attestation

As a Personal Representative of the patient, my signature certifies that (1) I have the right to do so on the patient’s behalf, (2) if possible, I’ve explained to the patient the nature and purpose of this application, (3) the information set forth above is, to the best of my knowledge, truthful and complete, and (4) I consent to Ambry’s use of the information to assess and/or verify eligibility for assistance.