By submitting your 1040 tax form and email address for the Myriad’s Financial Assistance Program Application, you agree to the following:

• If I do not have insurance, I certify I am not eligible for Medicare, Medicaid, or any other state or government health insurance and will not seek reimbursement from any insurance carrier or government agency for fees waived.
• If I have insurance, I certify that I will not seek reimbursement from any insurance carrier or government agency for fees that are my financial responsibility.
• I certify that the information contained in this application is correct to the best of my knowledge. I understand this information will not be used for any other purpose unless I give written consent, or to the extent necessary to document my eligibility under Myriad’s Financial Assistance Program.
• I certify I will notify Myriad’s Financial Assistance Program within 30 days if there is any change in my eligibility status with regard to income and health care coverage. I will provide documentation, including but not limited to personal financial records, which are necessary to verify the information contained in this application.
• By agreeing to testing, I authorize Billing to obtain a consumer credit report on me from a consumer reporting agency selected by Billing. I understand and agree that Billing may use my consumer credit report to confirm whether my income qualifies me for financial assistance. I further understand that this will be a soft credit inquiry and will not impact my credit in any way.
• If I qualify for financial assistance, I agree to provide Billing with any additional information or documentation that may be needed to confirm my qualification for the financial assistance program.

Medical Eligibility