Financial Assistance Program Application

Financial Assistance Program Application
Thank you for your interest in Ambry Genetics Corporation Financial Assistance Program.

Complete all fields below. We will process your request and notify you of your eligibility.

For additional information, please see Ambry's Patient Billing webpage.

Note: An incomplete request will delay processing.
Patient Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Sex Assigned at Birth
Address

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Phone Number
Please enter a valid phone number. This number may be used to contact you via phone or sms messaging. Voice or Data Rates May Apply.Format: (000) 000-0000.
E-Mail Address
Enter email address to receive all communications regarding this application
MKT-CORP-FORM-88888-EN v2 09.28.2025

Financial Assistance Program Application
Consent to Application:
Attestation

By signing and submitting this application, I (1) consent to receive genetic testing ordered by my healthcare provider; (2) certify that all information provided is truthful and complete, and understand that financial assistance may be withdrawn if the information is inaccurate; (3) consent to Tempus’ use of the information to assess and/or verify eligibility for assistance, and when applicable, Tempus may disclose the information above, as well as any eligibility determination that Tempus makes, to a Tempus contracted reference laboratory for its use to assess and/or verify eligibility for its financial assistance program; and (4) acknowledge that I have been provided with information regarding where to find applicable privacy policies, including the Notice of Privacy Practices, which explain how my health information and specimens may be used and Tempus’ practices for using de-identified data for any lawful purposes. To opt out of certain secondary uses of de-identified data, please click here. Your preferences with respect to secondary data use will have no impact on your eligibility for financial assistance.
Attestation

As a Legally Authorized Personal Representative of the patient, my signature certifies that: (1) I have the right to submit this application on the patient’s behalf; (2) if possible, I’ve explained to the patient the nature and purpose of this application; (3) the information set forth above is, to the best of my knowledge, truthful and complete; (4) I consent to the genetic testing ordered by the patient’s healthcare provider; (5) I consent to Tempus’ use of the information to assess and/or verify eligibility for assistance, and when applicable, Tempus may disclose the information above, as well as any eligibility determination that Tempus makes, to a Tempus contracted reference laboratory for its use to assess and/or verify eligibility for its financial assistance program; and (6) I have been provided with information regarding where to find applicable privacy policies, including the Notice of Privacy Practices, which explain how the patient’s health information and specimens may be used and Tempus’ practices for using de-identified data for any lawful purpose. To opt out of certain secondary uses of the patient’s de-identified data, please click here. The patient’s preferences with respect to secondary data use will have no impact on their eligibility for financial assistance.
Print Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
Email
example@example.com
Upload Supporting Documents

Cancelof
Signature
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MKT-CORP-FORM-88888-EN v2 09.28.2025
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Financial Assistance Program Application

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Financial Assistance Program Application