TESTIMONIAL HIPAA AUTHORIZATION
At Quest Diagnostics®, we appreciate that you have a story to tell and want to share your experience with others. Quest Diagnostics Incorporated and its affiliated clinical laboratories (Quest Diagnostics ) conducted the testing that is part of your story.
By signing below, I give my permission and authorize Quest Diagnostics to collect, use, and disclose my protected health information (also called PHI) listed below to the Recipients for the Purposes described in this Authorization. Recipients of your PHI may include the following: news outlets; advertisers; internet posts and outlets; social media outlets; the general public; Quest Diagnostics Foundation, Inc; non-laboratory affiliates and divisions that are part of the Quest Diagnostics family of companies (“Quest-Related Companies” ); entities that assist Quest Diagnostics and Quest-Related Companies; and third parties that conduct and evaluate promotional campaigns.
Quest Diagnostics would like to use/disclose your PHI for some or all the following Purposes : press releases; making promotional materials; promoting and publicizing Quest Diagnostics and Quest-Related Companies and their products, services, events, and activities in the community; and advertising and other commercial uses for Quest Diagnostics and Quest-Related Companies.
This Authorization applies to my identifying information and demographics —first and last name, demographic information, geographic information (eg, IP address, contact information)—and how I have interacted with Quest Diagnostics as well as the following PHI :
Laboratory testing ORDERS related to
Laboratory testing RESULTS, DIAGNOSES, AND MEDICAL CONDITION INFORMATION related to
I understand that the information used and/or disclosed pursuant to this Authorization may be re-disclosed by the person or party receiving it and will no longer be protected under federal privacy law.
This Authorization becomes effective upon my signature and will not expire until I revoke it in writing or until Quest Diagnostics and Quest-Related Companies cease their publicity and promotional activities.
Notice to the patient:
This Authorization is optional. You may refuse to sign it and still receive services from Quest Diagnostics
Quest Diagnostics cannot condition its provision of services to you on the receipt of this signed Authorization
You may request a copy of your PHI to be used or disclosed
Quest Diagnostics must provide you with a copy of this signed Authorization, upon request
This Authorization only covers your PHI that is used or disclosed by Quest Diagnostics
You have the right to revoke this Authorization at any time, provided that you do so by sending a written notice of revocation to QuestConsumerMarketing@questdiagnostics.com or to the attention of the Marketing Department, 500 Plaza Drive, Secaucus, NJ 07094. Your revocation only applies to uses of your information after we receive it and does not affect any prior use or disclosure made in reliance upon this Authorization
I have read and understand this Authorization, and I authorize the use, disclosure, and dissemination of my PHI as set forth above.
I agree to sign this Authorization electronically by typing my name below and selecting "Accept."
Patient Information
First name *
Last name *
Date of birth *
Phone number *
Address *
Electronic Communication Security
While we attempt to send emails securely, they may not remain encrypted during transmission. There is a risk that electronic communications, including emails and texts, could be intercepted or viewed by a third party. Once received by you, anyone with access to your email account or device can see your emails or texts. By choosing to receive electronic communications from Quest Diagnostics, you acknowledge and accept these risks.