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I authorize (i.e., allow) the use and/or disclosure of my Protected Health Information, described below, as permitted by this authorization.

1. The entity/entities that may disclose my Protected Health Information:

Quest Diagnostics Incorporated and its subsidiaries and affiliates that provide clinical laboratory services (“Quest Diagnostics”) and its service providers.

2. The Protected Health Information that may be disclosed:

My entire medical record for the services purchased on [DATE] through Get Baseline, Inc’s application(s), including information on my medical condition(s), medical history, purchase history, and testing information and results and all other identifiable health information about me.

I specifically authorize the release of my Protected Health Information (if any) that includes sensitive information and records, such as information on genetic testing.

3. The entity/entities authorized to receive my Protected Health Information:

Get Baseline, Inc. (“Baseline”) and its service providers.

4. Purpose(s) for the collection, use and/or disclosure of Protected Health Information:

To disclose my Protected Health Information to Baseline, which is a consumer health company, at my request.

5. No conditioning of treatment or certain other activities on acceptance of this authorization:

I understand that I am not required to sign this authorization and it is completely voluntary. Quest Diagnostics cannot require me to sign this Authorization as a condition to providing services to me.

6. Right to revoke.

I may revoke (i.e., take back) this authorization at any time, except to the extent that Quest Diagnostics has taken any action in reliance on my authorization. I understand that if I revoke this authorization, it will not have any effect on any uses or disclosures of my Protected Health Information that occurred prior to receiving my revocation. To revoke, I may email PAARevocation@questdiagnostics.com.

7. Expiration.

This authorization will remain in full force and effect for two years, unless I revoke it prior to this time.

8. Potential for re-disclosure.

Protected Health Information disclosed under this authorization may be re-disclosed by recipients of the data and no longer protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and applicable regulations, as amended.

9. Copy of authorization.

I understand that a signed copy of this authorization is available to me upon request. I have read this authorization and/or had its contents read to me. I fully understand the terms and conditions, and I am signing this authorization on my own free will. I authorize the use and disclosure of my Protected Health Information as described in Sections 1-9 above.