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DISCLAIMER

Your signature constitutes a Statement of Medical Necessity (SOMN) and your
attestation of the following: (1) Accurate clinical information has been entered
above. (2) The patient meets the test criteria. (3) I have evaluated the
risk/benefit profile of the test and the test is medically necessary and test
results will be used with other clinical data to assess the probability of
allograft injury, rejection or otherwise to inform clinical decision making and
to aid in guiding treatment decisions for the patient. (4) The patient has
consented for this test to be performed and for CareDx to release test
information for treatment, care coordination, and/or when necessary to obtain
reimbursement or payment. (5) Physician or physician’s delegate has the
authorization to sign support forms and documents on behalf of the ordering
physician for CareDx Orders (electronic,PA signature requirements).
Acknowledgment: Your signature on this form indicates that the physician or
physician’s delegate has obtained all requisite authorizations from the patient
necessary to authorize the release of any medical and insurance information
necessary to process claims for services provided by CareDx, Inc., and has
obtained all requisite authorizations to assign the right of the patient to, and
authorize payment to CareDx, Inc. for all services provided by CareDx, Inc.
CareDx, Inc. is authorized to pursue all necessary appeals of full or partial
payment on behalf of the patient with his or her health insurance company in
relation to services provided by CareDx, Inc. In exchange for this assignment of
benefits, CareDx, Inc. agrees to accept assignment from the patient’s health
insurance company as payment in full.