LABCORP FACSIMILE VERIFICATION FORM
The undersigned health care provider hereby authorizes LabCorp 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.
The undersigned health care provider may revoke this authorization or change the fax number, provided that the undersigned health care provider gives LabCorp reasonable written notice.
be faxed to (858) 486-5806 AND/OR emailed to
LabCorp strongly encourages all clients to physically safeguard fax machines, so that the location, access, and use of such machines comply with all HIPAA requirements.
Purpose of Request
New fax route
Update existing route
Alternate/Temporary authorized fax
Report Type Requested
*Fax Number 1
Fax Number 2
Fax Number 3
Provide Area Code with each fax number.
Seperate accounts using a comma ( , ).
District of Columbia
( Representative is usually the person filling out this form )
Comments / Special Instructions
*Confirm Email Address