printable fax cover sheet with confidentiality statement

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Fax Cover Sheet To: Fax: Quest Diagnostics (877) 396-3645 From: Pages: 2 Date: cc: Phone: (800) 354-1703 Re: Home Depot Hidden Health Risk Physician Waiver Please use this fax cover sheet when returning
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F.R. Part 164]. If you have a HIPPO Privacy Rule compliant form of e-mail, please send the enclosed e-mail from this address back to the original sender. Thanks for your help. The Quest Diagnostics Health Risk Assessment (DHA) Process and Ordering Information is a summary of the process for ordering a screening physician or test (Physician Waiver) directly from Quest Diagnostics. This list was originally provided by Quest Diagnostics. For additional information on ordering and the DHA process, please read the DHA Ordering Information page and/or call Quest Diagnostics. To order a DHA from Quest Diagnostics, send an e-mail to and include: Order number Name Telephone number for Order #1 (optional but strongly recommended if you don't have a registered phone number) Name of physician or test to be ordered Date you would like information. The form number from the Order number section of the DHA Ordering Information page. A signed e-mail confirmation must be emailed back to the original sender after the information is received. This document should be mailed to: Dr. Ronald Fun, Patient ID No. Patient's Name at the time of diagnosis A short description of the treatment or diagnosis, which should be clear to the patient and others who may have contact with the patient. If it is impossible to adequately describe what is being investigated, please include a brief description. Your email address, mailing address, and telephone number A signature. All e-mails should be sent from the name listed in the email header. Requirement that any information you provide be given in confidence or not released to third parties. Any personal information which may be used or released by the provider or others for direct marketing purposes, including without limitation mailing lists, Internet usage information, contact information, home mailing lists or lists obtained through other marketing efforts (e.g., social media), will NOT be released. If you want to receive your DHA, mail your mail and any payment information to: Quest Diagnostics Customer Service 1 Quest Diagnostics Drive Suite 400 Westfield, CT 06821 Attention: Information Order Receipts.
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