Certificate of Medical Necessity and Informed Consent

I attest that:

a) PrismRA is medically necessary for the patient
b) The test information will inform the patient’s ongoing treatment plan
c) I am the patient’s treating provider

I have explained to the patient the nature and purpose of the test and have obtained the patient’s informed consent, to the extent legally required, to permit Scipher Medicine to:

a) Perform the PrismRA test
b) Retain the test results and samples for an indefinite period of time for internal quality assurance and operations purposes
c) Remove information that directly identifies the patient from the test results and genetic material, and use or disclose such information and materials for future unspecified research or other purposes
d) Release the test results and related patient information to the patient’s third-party payer as needed for reimbursement purposes