Protected Health Information Fax
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|To: | |Fax: | |
|From: | (Referral Testing) |Date: | |
|Re: | |Pages: | |
|CC: | |Return Fax | 610-271-9734 |
|X Urgent | For Review | Please Comment |X Please Reply | Please Recycle |
Notes:
Attached please find the waiver for Huntington’s Disease testing. We MUST receive a signed waiver before we can perform the test. Please keep in mind the sample is only stable 8 days.
Please have the referring physician complete the attached form and indicate whether the patient is symptomatic or has a positive family history where indicated on the form. Then fax to number listed on bottom of the form and fax a copy to me for tracking purposes.
If you have any questions, please contact me at the above number.
Thanks,
Ginny Jolley
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Quest Diagnostics Nichols Institute Incorporated
Department: Client Services
Address: 14225 Newbrook Drive
Chantilly, Virginia 20151
800-336-3718 ext 62630
PROTECTED HEALTH INFORMATION
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