Acknowledgment:

Your signature constitutes a statement of medical necessity and your attestation that the test was ordered after evaluating its risk/benefit profile, is reasonable and medically necessary, and will be used in the clinical management of the patient. Your signature on this form also indicates that the physician or physician’s delegate has obtained all necessary 1) authorizations from the patient to release any medical and insurance information to process claims for services provided by CareDx, Inc., and 2) authorizations to assign the right of the patient to, and authorize payment to CareDx, Inc.