CENTERWELL PHARMACY, INC.

Patient Consent and Acknowledgement

By accepting this Consent and Acknowledgement, I am authorizing my healthcare provider to submit my prescription to CenterWell Pharmacy, Inc. ("CenterWell Pharmacy") for fulfillment and dispensing through its mail order facilities. I acknowledge that I have the right to have my prescription sent to a pharmacy of my choice; however, the discounted price for my Medication may only be available if it is dispensed by CenterWell Pharmacy. I choose CenterWell Pharmacy as the dispensing pharmacy for my Medication.

I understand that if I am enrolled in a commercial insurance program, government-sponsored health care program, or public assistance program (i.e., Medicare, Medicaid, TRICARE) (collectively, "Third Party Program"), I cannot utilize the benefits of such Third Party Program in the purchase of my Medication. I understand that any cost I incur in purchasing Medication through ApalyRx will not count toward my out-of-pocket expense for such Third Party Program. I acknowledge and agree that I cannot and will not submit any claim regarding my Medication to any Third Party Program.