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The undersigned health care provider hereby authorizes Lab Corp and its subsidiaries to send patient protected health information (PHI) as defined by HIPAA (Health Insurance Portability and Accountability Act of 1996) to the fax number listed below.

Additionally, the undersigned health care provider understands that it has deemed such transmission is necessary for the purposes of health care treatment, payment, and/or health care operations.

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The undersigned health care provider may revoke this authorization or change the fax number, provided that the undersigned health care provider gives Lab Corp reasonable written notice.

Such notice MUST be faxed to (858) 486-5806 AND/OR emailed to [email protected]

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