I understand that the address written on the test requisition form, which may be my primary residence, is within a state not currently eligible for Direct Access Testing (DAT).

This attestation verifies that I collected my specimen within the approved DAT state written below. I also verify that I placed the provided paperwork in the provided biohazard bag and then placed both in a return shipping package that was given to an office or driver.

DAT States: AK, AR, AZ, DE, IN, IA, KS, LA, MN, MS, MO, MT, NE, NM, NC, ND, OH, OK, SD, UT, VT, WA, WV, WI, TX, VA, District of Columbia.

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Printed Name of Legally Authorized Representative (if applicable)