"For each employee benefit plan where I am enrolled to use the Card, I certify that I will only access my plan account through the Card for payment of qualifying expenses under that plan. I acknowledge that I have received and reviewed guidelines on the expenses that can be qualifying expenses under each Card plan, and I agree to follow these guidelines. I also agree and affirm that any expense I pay with the Card will not be submitted (and will not have been submitted previously) for reimbursement to any other plan or program of benefit coverage. Further, I agree to save all invoices and receipts for any expense I pay with the Card and, upon request, to submit these documents for review by the applicable Card plan.

I acknowledge that in order to process my Card transactions it may be necessary to disclose information regarding my participation in my plan to third party service providers (such as benefits administrators that determine pharmacy benefits under group health plans) that are not processing transactions for my plan. The information that would be disclosed would be limited to my name and/or my social security number or other unique identifier, and my plan effective and termination dates. These third party service providers will be contractually prohibited from both using and disclosing to others this information.

I hereby request that you refrain from sending me annual privacy notices. I understand that the current privacy notice is available to me at any time by accessing it on the web site, http://www.wexhealthinc.com/privacy-policy or by calling my Administrator at the number on the back of my Card.

I agree and consent to the foregoing disclosure each time I use the Card or permit the Card to be used for payment. I understand that I may withdraw this consent at any time by calling the telephone number on the back of my Card, but if I withdraw my consent I will no longer be entitled to use the Card.

The promises and consents above will be considered ‘My Use of Card Promises,’ and I understand that my acceptance of these promises (by activation of the Card) and your reliance on them has created a binding contractual commitment on my part regarding my use of the Card. I also understand that I will renew and reaffirm My Use of Card Promises each time I use or permit the Card to be used for payment."