Shipping Information Form

By signing below I acknowledge:

1. No test other than the specific test(s) ordered shall be performed on the biological sample.

2. I, voluntarily consent to the collection and testing of my specimen. I understand that I am responsible for all co-pays and deductibles, and for amounts not covered by Insurance. By signing this authorization I am acknowledging that payment(s) be made on my behalf to Infinite Laboratories for any services provided to me by Infinite Laboratories. I also allow the release of any medical information necessary to process this claim.

3. I understand that my insurance company may send the benefit payment directly to me and I agree to forward that payment endorsed and un-cashed to: Infinite Laboratories, 5555 Oakbrooke Pkwy Building 100 STE # 140 Norcross, GA 30093.

4. The information in the patient information section is accurate and I give Infinite Allergy Labs consent to release results to the email address listed in the Patient Information Section when applicable.

5. I authorize the release of reports to both the ordering and referring provider, when applicable. In Instances such as where the referral was made by a provider who cannot directly order tests under my Insurance plan. I affirm my consent for the sharing of relevant medical information between the ordering and referring parties.

I authorize the laboratory test(s) as ordered, and affirm that each are both medically necessary and correspond to the patient's diagnosis as submitted to the laboratory for testing. I understand that each test ordered is a billable event, and the patients medical record(s) must clearly reflect my order. For Medical Necessity Authorization Form, please refer to the backside of this document.

To whom it may concern,

I am the physician for the patient noted above and writing to request coverage for the diagnostic Food Allergy/Sensitivity Test performed by Infinite Allergy Labs for my patient. I consider this test a medically necessary step in the diagnosis and treatment of my patient due to their medical history, and there is no In-network laboratory in my area able to provide comparable testing.

Food Sensitivities cause a range of illness and symptoms, including skin rashes and chronic intestinal diseases. The Infinite Allergy Labs FAST Panel measures over 88 of the most common foods and additives. This yields many benefits, including uncovering which foods are causing inflammation and disease, developing a personalized nutritional guide, and improving a patient's state of health and energy levels. The test is the most sensitive food test available methods that detect both IgG, IgG4, IgE, and C3b/d antibodies and complement antigen together to determine the reactivity of each sample against a wide variety of food antigens using the most up to date technology.

Food elimination based on the Infinite Allergy Labs FAST Panel results has been shown to significantly reduce symptoms a patient is experiencing.

Laboratory Performing Test: Infinite Allergy Labs - a high complexity CLIA laboratory located at 5555 Oakbrook Pkwy Building 100 STE # 140 Norcross, GA 30093

CLIA ID#: 11D2142105, Phone: 1-833-FOODALLERGY www.infiniteallergylabs.com

This document should include a place for the Physician signature or initials.