Appointment of representative

I, [Patient Name], appoint Fast Lab Technologies LLC., to act on my behalf in connection with any claim for coverage or benefits identified in this case, including receipt of any approval(s) or authorization(s) that are required before medical service(s) are provided, or in order to receive any payments due under my insurance benefits for the service(s) Fast Lab provided. I authorize my representative to receive any and all information related to this case that is provided to me and to provide any information to the health plan in relation to the disputed claims, approvals, or authorizations. This information may include a diagnosis (name of illness or condition), progress notes or other supporting documentation, claims, doctors and other health care providers and financial information (like billing and banking). I also understand that I may revoke (or cancel) this approval at any time, and that this Appointment shall cease as soon as Fast Lab has received payment in full and remedies under applicable regulatory guidelines for all medical care services provided to me. I hereby confirm and ratify all action taken by my Representative pursuant to the authority granted herein.