GLTrax

What I am authorizing

I authorize GLTrax, LLC ("GLTrax") to submit a laboratory testing order on my behalf, and to disclose the information described below to FPK Services LLC d/b/a Analyte Health ("Analyte Health"), to its affiliated clinicians at Wilcrest Medical Group, and to the performing laboratory and patient service centre, for the purpose of ordering, authorizing, and performing the laboratory tests I have selected.

Information disclosed

• My full legal name, date of birth, and sex
• My phone number, email address, and mailing address where provided
• The laboratory panel and tests I selected, and the associated laboratory test codes
• Any clinical information I chose to include with my order, such as notes about my medications or symptoms
• Payment status for the order (whether it is paid), but not my card details

Who receives it and why

Analyte Health and its affiliated clinicians at Wilcrest Medical Group receive it in order to review my order and, if clinically appropriate, sign a laboratory requisition authorizing the testing. I understand that a clinician at Wilcrest Medical Group — not GLTrax — will be the ordering clinician and will form a clinician-patient relationship with me, and that this clinician may decline to order any test.

The performing laboratory and patient service centre receive it in order to identify me, collect my specimen, and perform the testing.

What I understand about GLTrax's role

• GLTrax is not a healthcare provider, is not a HIPAA Covered Entity or Business Associate, and does not perform, review, or interpret laboratory testing.
• GLTrax submits my order as I have entered it and is not responsible for information I entered incorrectly.
• GLTrax and Analyte Health may each decline, suspend, or cancel any order at their discretion.
• The clinician who signs my requisition is not my primary healthcare provider, will not treat me, and will not follow up with me about my results.
• These services are cash-pay only. No claim will be submitted to insurance, Medicare, Medicaid, TriCare, or any other federal or state healthcare programme.

My representations

• I am at least 18 years old.
• I am ordering this testing for myself and no one else.
• The information I have provided is accurate, current, and complete, and I understand that inaccurate information may delay or invalidate my order and may make it non-refundable.
• I am voluntarily requesting this testing. No one is requiring me to obtain it.

My right to revoke

Revocation takes effect when GLTrax receives it and applies going forward only. It does not undo any disclosure already made while this authorization was in force, and it does not by itself cancel or refund an order already placed. If my order has already been submitted, revoking will not stop the clinician or laboratory from completing testing already underway. After revoking I must sign a new authorization before placing another order.

Expiration

This authorization expires 10 years from the date I sign it, or on the date I revoke it or close my GLTrax account, whichever comes first.

Redisclosure

I understand that once my information is disclosed to Analyte Health, Wilcrest Medical Group, and the performing laboratory, they hold it as a healthcare provider under HIPAA and their own Notice of Privacy Practices governs it, not GLTrax's Privacy Policy.

Voluntary; no conditioning

Signing this authorization is voluntary. GLTrax will not condition my access to the GLTrax app, or to any non-laboratory feature of it, on whether I sign. However, GLTrax cannot place a laboratory order for me without it — that is the purpose of the authorization, not a penalty for declining.

I am entitled to a copy of this authorization. A signed copy is available at any time in Settings → Lab authorizations.

Document version 2026-08-05.2. This is the current version of the text. You sign it as part of placing a lab order; the copy you signed, with its version and date, is available in Settings → Lab authorizations.