Patient Request to Access or Disclose PHI
This file is used by patients to request access to or disclosure of their Protected Health Information (PHI) from Quest Diagnostics. It includes sections for patient information, test order details, identification verification, and delivery instructions. Submit the completed form to Quest Diagnostics via mail, fax, or email.
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How do I fill this out?
To fill out this form, you need to provide your personal details, test order information, and identification verification. Follow the instructions carefully to ensure accurate and complete submission. This introduction will guide you through the initial steps.
How to fill out the Patient Request to Access or Disclose PHI?
1
Fill in the patient's personal information in Section A.
2
Provide test order details in Section B.
3
Verify your identification in Section C.
4
Specify delivery instructions in Section D.
5
Sign and submit the form as instructed in Section F.
Who needs the Patient Request to Access or Disclose PHI?
1
Patients who want to access their laboratory test results.
2
Parents of minor patients requesting their child's PHI.
3
Legal guardians who need to access the PHI of their ward.
4
Authorized representatives requesting PHI on behalf of a patient.
5
Healthcare providers needing additional PHI for patient care.
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Edit text, add annotations, and customize the document.
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Review the changes for accuracy.
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What are the instructions for submitting this form?
Submit this completed Access Form (and any proof of representation, if required) to Quest Diagnostics, 9601 Renner Blvd, Lenexa, Kansas 66219, ATTN: Clinical Client Services. Alternatively, you can fax the form to 1-855-854-9151 or email it to KCNOCRequesttoAccess@questdiagnostics.com. Ensure that you have filled out all required sections and provided accurate information for a smooth submission process.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates for this form in 2024 and 2025. Ensure that you submit the form as soon as possible to avoid delays in processing.
What is the purpose of this form?
The purpose of this form is to enable patients to request access to or the disclosure of their Protected Health Information (PHI) from Quest Diagnostics. By filling out this form, patients can obtain their laboratory test results or have their PHI shared with designated individuals or entities. This form ensures that all necessary information is provided to process the request accurately and efficiently.
Tell me about this form and its components and fields line-by-line.
- 1. Patient's Information: Includes fields for the patient's name, date of birth, address, and Social Security Number.
- 2. Test Order Information: Collects details about the test order, including the ordering physician's name, address, and requested PHI.
- 3. Identification: Verification of the requester's identity, including options for the patient, parent, legal guardian, or authorized representative.
- 4. Delivery Instructions: Specifies how the PHI should be delivered, including options for mail, fax, or email.
- 5. Signature: Requires the requester's signature and date of submission.
What happens if I fail to submit this form?
If you fail to submit this form, your request for access to or disclosure of PHI will not be processed. This can lead to delays in obtaining necessary information.
- Delay in Receiving Test Results: Without submission, you will not receive the requested laboratory test results.
- Incomplete Medical Records: Failure to submit may result in gaps in your medical records, affecting ongoing care.
- Unprocessed Requests: Your request for PHI disclosure will remain unprocessed, impacting any planned sharing of information with designated parties.
How do I know when to use this form?
- 1. Accessing Personal Test Results: Use the form to obtain your laboratory test results from Quest Diagnostics.
- 2. Requesting PHI for Minor Children: Parents can use this form to request their child's PHI.
- 3. Accessing PHI for Legal Wards: Legal guardians can submit this form to access PHI for their wards.
- 4. Authorized Representatives Request: Authorized representatives need this form to request PHI on behalf of patients.
- 5. Healthcare Provider Requests: Healthcare providers may use this form to obtain additional PHI for patient care.
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