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By clicking next, you hereby assign and convey directly to GENETWORx as your designated authorized representative, all medical benefits and/or insurance reimbursement, if any, otherwise payable to you for services, treatments, therapies, and/or medications rendered or provided by GENETWORx, regardless of its managed care network participation status. You authorize your insurance carrier(s) to remit payment of benefits for any claim for services provided by GENETWORx directly to GENETWORx .

You agree to assign GENETWORx as your Authorized Representative to (1) submit any and all appeals if your insurance company denies you coverage to which you are entitled; (2) submit any and all requests for benefit information from your insurance, and (3) sue anyone in its own name as your authorized representative to obtain payment for charges relating to your care and payment for lawyers’ fees resulting from efforts to obtain payment. This assignment is valid for all administrative and judicial reviews under PPACA (health care reform legislation), ERISA, Medicare and applicable federal and state laws. You also appoint GENETWORx as your attorney-in-fact to present, with respect to obtaining payment and/or receiving reimbursement for GENETWORx’s services.