I understand Medi-Lynx Cardiac Monitoring, LLC ("MediLynx") may verify the financial information contained in the Financial Assistance Application ("Application") in connection with MediLynx' evaluation of this Application, and by my electronic signature hereby authorize my employer or any individual listed on this Application to certify or provide additional detail with respect to the information provided in this Application. I certify that the statements made in this Application are true and correct, to the best of my knowledge and belief, and are made in good faith. I am aware that falsification or misrepresentation of information on this Application may result in denial of financial assistance.

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