This document is incorporated into your agreement with Terra (through the consent provision of your Order or Schedule or, for customers on Terra's standard clinical agreement, the Clinical Services Schedule) and specifies every consent and disclosure your application must present to, and capture from, US end users before they receive clinical services through the Vantage API — including text required by the physician networks and laboratories in Terra's fulfillment chain. Terra may update this document from time to time and will give you reasonable notice of material changes; implement updates promptly.How text is marked
Every block carries one of three tiers:•
VERBATIM— mandated by an upstream provider or by law. Deploy exactly as printed; populate only bracketed slots where instructed. Deviation is a breach of your agreement with Terra, and Terra cannot agree variations.
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REQUIRED CONTENT— the substance and every named entity are mandatory; you may adapt the wording to your application's style.
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TERRA REQUIRED— mandated by Terra (not by an upstream provider or by law). Deploy as printed; Terra may agree a variation in writing.
| Question | If yes |
| Do you have US end users? | All of §2, §4, §5, §6 |
| Are you a HIPAA covered entity or business associate with a BAA with Terra? | You are US B2B — skip §3.1 |
| US end users but no BAA with Terra? | You are US DTC — §3.1 is mandatory |
| Is testing ordered through Terra's physician network (all consumer/self-order flows, and any flow where your own clinicians do not order)? | Blocks marked [PN] apply |
| Does your menu include genetic testing? | §3.2 |
2(a) Physician-network authorization and consentVERBATIMPN
I voluntarily consent and authorize CWI Physician Partners P.C., a California Professional Corporation; CWI Physician Partners P.C., a Hawaii Professional Corporation; CWI Physician Partners P.C., a Georgia Professional Corporation; CWI Physician Partners P.A., a Kansas Professional Association; CWI Physician Partners P.C., an Oregon Professional Corporation; CWI Physician Partners P.C., a Nevada Professional Corporation; CWI Physician Partners P.C., a Rhode Island Professional Corporation; CWI Physician Partners P.C., an Oklahoma Professional Corporation (collectively, "CWI") to review the collection, testing, and analysis for the purposes of a diagnostic screening test. I understand that there are risks and benefits associated with undergoing a diagnostic screening testing and there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have question or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider. I further acknowledge the following:
- I am the individual who will provide the sample for the Test(s) that I am requesting or I am the parent or legal guardian of a minor who is providing the sample for testing.
- I am at least eighteen (18) years of age or I am the parent or legal guardian of a minor who is providing the sample for testing.
- I have read and understand the information provided about the Test(s) that I have been provided on the website where I requested the Test.
- The information I have provided in connection with my request to CWI is correct to the best of my knowledge. I will not hold CWI or its employees or agents responsible for any errors or omissions that I may have made in providing such information.
- My health information and results may be shared with CWI employees and agents for the purpose of ordering, processing, and reporting my results.
- Medical Services provided by CWI are purely for diagnostic assistance purposes and do not create a physician-patient relationship, and do not constitute medical care or diagnosis or treatment of any condition, disease, or illness.
- I authorize CWI to contact me via text message to communicate with me regarding my test.
2(b) Recipient chainREQUIRED CONTENT
The consent must identify everyone who receives the end user's information, by name:My information, sample, and results may be shared among: CWI (the ordering physician network); the laboratory performing my test — imaware, Inc., Clinical Reference Laboratory, Inc., or Quest Diagnostics, as applicable to the test and collection method I select; the application through which I placed my order; and Terra Enabling Developers, Inc., the technology platform that routes my order and results between them.
2(c) Patient rights and privacy practicesVERBATIMPN
Notice of Privacy Practices and Patient Rights: CWI Physician Partners P.C. Notice of Privacy Practices describes how it may use and disclose your protected health information for other purposes that are permitted or required by law. To review a copy of CWI Physician Partners P.C. Notice of Privacy Practices, go to www.CynergyWellness.com.
2(d) Disclosure to government authoritiesVERBATIM
Disclosure to Government Authorities: I acknowledge and agree that my test results and associated information may be disclosed to appropriate county, state, or other governmental and regulatory entities as may be permitted by law.
2(e) ReleaseVERBATIM
To the fullest extent permitted by law, I hereby release, discharge and hold harmless, CWI and the technology platform that routed my order (the "Platform Provider"), including, without limitation, any of their respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my diagnostic test or the disclosure of my test results.
2(f) Alert-contact waiverTERRA REQUIRED
I expressly consent to receive communications — including calls and text messages, and including those made using automated technology — from the physician network, the laboratory, or their representatives where they reasonably believe contact is necessary in connection with my test results. This consent is not a condition of purchase of any other good or service. To the fullest extent permitted by law, I also waive any claim arising from such contact.
2(g) Results notification consentTERRA REQUIRED
I understand that once my test results are ready, I will be notified, and I may access my results by logging in to the application. I understand that these notifications may include protected health information, and I agree that the application and its service providers are authorized to send them.
2(h) Acceptance mechanicsVERBATIM closing line
By selecting the ACKNOWLEDGEMENT during the registration process for diagnostic testing, I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I have read the contents of this form in its entirety and voluntarily consent to proceed with these procedures.
Capture rules: one affirmative act covers §2 as a single instrument; log the acceptance per §5; re-present on any material text change. The invalidity or unenforceability of any block does not affect the validity or enforceability of the remaining blocks.End User Agreement clause (your ToS/EULA must contain this)TERRA REQUIRED
You agree that the ordering provider, the laboratory, and the technology platform that routed your order (the "Platform Provider") are intended third-party beneficiaries of, and may enforce, the releases, disclaimers, acknowledgments, and consents you provide under this Agreement and in connection with the services.
3. Standalone captures — never bundle these into §2 or your Terms of Service3.1 US DTC Data Authorization (DTC only — no BAA with Terra). The end user must sign the standalone health-information authorization supplied by Terra (Terra's DTC Data Authorization instrument).3.2 Genetic express consent (genetic testing only). A distinct affirmative act consenting to genetic testing and processing, naming who has access. Where the Data Authorization applies, the genetic consent folds into it. Do not offer sample-storage or secondary-use consent options — those activities are prohibited under your agreement, and no consent for them is offered by design.4. At results1.
Before results are shown, the end user acknowledges readiness by an affirmative action — a checkbox (or equivalent) that un-gates the results view. On that action, call Terra's results-acknowledgment endpoint and promptly display the results in full.
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Never trigger the acknowledgment from webhook receipt, result retrieval, or any other backend event — it must evidence the end user's own action.
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If results remain unacknowledged, the responsible physician network's clinicians may contact the end user directly (see §2(f)).
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Direct-access election — TERRA REQUIRED, captured with the acknowledgment or at checkout (your choice):
I elect to exercise my right of direct access to my test results, and to the extent permitted by law I waive any state result-release or waiting-period requirement that would delay my results being made available to me.
5.
Display results in accordance with Terra's Results Display and Clinical Escalation Requirements — in full, unaltered, with escalation messages reproduced verbatim.
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For every capture under this document, log: who accepted, the exact text version shown, when, and how. Retain these records in producible form.
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Provide the records to Terra on reasonable request connected to a provider requirement, audit, or regulatory inquiry.
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Annually, and on Terra's reasonable request, attest in writing that your consent and disclosure flow conforms to this document and your agreement with Terra.
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Keep your links (Terra's end-user disclosures page; provider privacy notices) pointing at the current versions.
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(Washington users) Maintain the separate consumer-health-data policy link Washington law requires of your application.
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Eligibility (18+). Enforce an age gate at checkout confirming the end user is at least eighteen (18) years of age, and do not offer testing to, or collect samples from, anyone under eighteen (18). This overrides any parent- or guardian-ordering language in the §2(a) verbatim block; do not enable any pediatric or guardian-ordering flow without Terra's prior written agreement.
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Available states. Gate checkout by the end user's state of residence and collection, accepting orders only from the states Terra publishes as available from time to time. Do not accept an order from an end user outside those states.
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PHI-minimal notifications. Notifications sent outside the authenticated application (push, SMS, or email) must not contain result values, panel names, or health conditions; limit them to a readiness message and a secure login link. Result content is shown only after login and the §4 acknowledgment.
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Opt-out pass-through. Where an end user revokes consent to be contacted or opts out of communications, honor the request and pass the revocation to the physician network and laboratory promptly.
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Do not edit, paraphrase, truncate, or restyle any [VERBATIM] block.
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Do not drop a named entity from a [REQUIRED CONTENT] block.
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Do not satisfy any capture with a passive link, pre-ticked box, or inferred acceptance.
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Do not bundle the US DTC Data Authorization with anything.
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Do not offer storage or secondary-use consent options for genetic data.
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Do not fire the results acknowledgment from your backend.
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Do not offer testing to, or collect samples from, anyone under eighteen (18); enforce the 18+ eligibility gate in the operational requirements above.
| Requirement | Source |
| Physician-network authorization/consent content | Required by the ordering physician network (CWI); informed-consent and §164.508-adjacent content |
| US authorization content & mechanics (DTC) | 45 CFR § 164.508; Cal. Civ. Code § 56.11 (form mechanics applied to all US users) |
| Anti-bundling | 45 CFR § 164.508(b)(3) |
| Genetic consent & prohibitions | Cal. SB 41 (Civ. Code § 56.18 et seq.); IL GIPA; GINA / CalGINA |
| US state overlays | CCPA/CPRA; WA My Health My Data; NV SB 370 |
| Contractual carrier | The consent provision of your Order or Schedule (for customers on Terra's standard clinical agreement, Clinical Services Schedule §§C4 and C6A); Terra's Results Display and Clinical Escalation Requirements |
