Authorization Agreement

aJust Solutions – Authorization Agreement

Designation of Authorized Representative, Payment Authorization, and Release of Information

Agency Appointment

Youvoluntarily appoint aJust Solutions, Inc.and its representatives(“aJust”) as your authorized agent to file a complaint, make an appeal,negotiate, settle, collect, and in any other way assist you with seeking a review of any denial, dispute, or adverse determination related to anyinsurance claims (collectively, “Claims”)for you, your children, and any individual thatyouhave legal authority over.

Payment Authorization

Youauthorize payment foranyClaimsto be made directly to aJust. You understand that aJust will receive a portion of the reimbursement amounts for the services it is providing to you and that any remaining amounts paid to aJust will be paid to you.

You agree that aJust has a lien on anyClaims that it has assisted you with and if a Claim is paid directly to youor any other party instead of aJust, you will immediately transfer to aJust an amount equal to their fee for such Claim. You further agree that if a claim is paid directly to aJust but is made in your name, aJust may endorse in your name such payment and deposit the payment intoaJust’s account.

Disclosure of Health Information

Youauthorize that all of your health information (or the health information of your children or individual that you have legal authority over, as applicable) may be disclosed to aJust. You understand that this information may contain medical, pharmacy, dental, vision, mental health, substance abuse, chronic disease, HIV/AIDS, psychotherapy, reproductive, communicable disease, alcohol or drug treatment, genetic marker, and other health care information.

Youauthorize aJust to release your health information as aJust deems necessary to provide services to you, including as necessary to file a complaint, make an appeal, and otherwise assist you with a Claim. You further understand that because of the authorization you are providing and any redisclosure of your records by aJust, your health information may no longer be protected by privacy laws (such as HIPAA).

You understand that this agreement can be revoked by you in writingat any time by terminating yourservices agreement with aJust in accordance with the Terms and Conditions.