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By creating an account on HealthX to receive COVID-19 tests on a monthly basis
through this website at no cost to me, I consent to the following:

1. I consent to the use of my Protected Health Information (“PHI”) by Mobvilvax LLC, for the purpose of submitting claims to my health insurance provider and such other purposes that are permitted under the federal Health Insurance Portability and Accountability Act (HIPAA) for reimbursement of COVID-19 tests ordered through this website.

2. I consent to Mobvilvax submitting claims to my health insurance provider on a monthly basis until such time as I notify Mobvilvax that I no longer wish to receive further COVID-19 tests, and I assign my right to receive any health insurance or other benefits in connection with the COVID-19 tests ordered through this website to Mobvilvax in order to permit Mobvilvax to submit such claims. I authorize Mobvilvax without notice, except where required by law, to send and bill my insurance provider and have payment sent directly to Mobvilvax for such claims.

3. I understand that select insurance plans may cover the cost of at-home COVID-19 tests and limits apply to the number of tests covered per person per month. After I request an order, Mobvilvax will attempt to confirm eligibility and copay amounts with you insurance provider.

4. I consent to Mobvilvax and/or my health insurance provider contacting me in connection with the COVID-19 tests ordered through this website, including via email, phone, or text message.

5. I consent to the Terms of Use, Privacy Policy and HIPAA Policy on HealthX’s Website,

6. I agree that all of the above consents apply to any other persons covered by my health insurance policy on whose behalf I order COVID-19 tests through this website, including any minors, and I affirm that I have the authority to order COVID-19 tests on such persons’ behalf, including any minors.

7. I agree that, by ordering COVID-19 tests through this website or taking such tests, I am not entering into a doctor-patient relationship with HealthX or any entity or person affiliated with HealthX, and that any questions I may have concerning such tests, including but not limited to the results of such tests and any treatment, follow up, or other issues relating to such tests, are solely my responsibility to contact HealthX.

8. By clicking on the “I Agree” checkbox while registering, I acknowledge that I have read, understand, and agree to all of the above provisions of this Consent, including HealthX’s Terms of Use and Privacy Policy. I further agree that I, as well as my heirs, executors, and assigns, and any other persons covered by my health insurance policy on whose behalf I have ordered COVID-19 tests, including any minors, hereby release Mobvilvax, including any of Mobvilvax owners, directors, officers, employees, agents, contractors, or other entities or persons affiliated with Mobvilvax, from any and all liability and claims in connection with such tests.

9. I understand that the exact test that will be shipped by HealthX is based on availability. The COVID -19 test kits have been authorized by the FDA under an emergency use authorization.

10. I understand that while I may cancel at any time, only future orders of test kits may be canceled. I agree that any test kit that has already been ordered and has had a claim submitted to my insurance company may not be canceled. I understand that the at-home testing program automatically renews unless canceled.

11. HealthX’s terms and conditions may be changed at any time

HIPPA Policy

I hereby authorize XPRESS and its affifiliates, its employees, and agents, to use and disclose protected health information (e.g., information relating to the diagnosis, claims payment, and health care services provided or to be provided to me and which identifies my name, address, date of birth or any other information that I provide to Xpress) for the purpose of helping to resolve claims and health benefit coverage issues. I understand that any personal health information or other information released to the person or organization identified may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws. I understand that I have a right to revoke this authorization by providing written notice to Xpress. However, this authorization may not be revoked if it’s employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization which is available on I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. I further understand that this authorization is voluntary. By agreeing to this HIPAA Privacy and Release of Information Authorization I represent that I am the legal person who is authorizing Xpress to obtain COVID-19 home test kits and that I am legally authorized to act with respect to this authorization form for myself or any other person for whom I order Covid-19 home test kits, including any minor.

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