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Get Quest Diagnostics Assistance

Dear Patient Thank you for your interest in our Patient Financial Assistance Program. Please complete the attached Patient Financial Assistance Application and return it to the correspondence address listed on your invoice. If you have questions or concerns please do not hesitate to contact us. Thank you for using Quest Diagnostics. We look forward to serving you in the future. Sincerely Patient Billing Customer Service Patient Financial Assistance Application Patient Name Telephone Number Address Patient Date of Birth City State Zip Invoice Number s Lab Code 1. We look forward to serving you in the future. Sincerely Patient Billing Customer Service Patient Financial Assistance Application Patient Name Telephone Number Address Patient Date of Birth City State Zip Invoice Number s Lab Code 1. Does the patient have medical insurance coverage Yes No If Yes please list responsible party information Please include a copy of insurance card. Insurance Carrier Name ID Policyholder Name 2. Total annual gross household income Total household income includes the following for all members of your household Gross Salary Unemployment Compensation Disability and Worker s Compensation Social Security and/or Supplemental SSI Benefits Public Assistance TANF SNAP etc. Other Income Number of family members in household supported by above income Optional Please advise of any extenuating circumstances that you would like us to consider. We will determine your eligibility once we receive your application* Please allow approximately two weeks for your application to be processed and do not make any payments until you receive notification regarding the status of your request. If you have questions or concerns please do not hesitate to contact us. Thank you for using Quest Diagnostics. We look forward to serving you in the future. Sincerely Patient Billing Customer Service Patient Financial Assistance Application Patient Name Telephone Number Address Patient Date of Birth City State Zip Invoice Number s Lab Code 1. Does the patient have medical insurance coverage Yes No If Yes please list responsible party information Please include a copy of insurance card. Insurance Carrier Name ID Policyholder Name 2. Total annual gross household income Total household income includes the following for all members of your household Gross Salary Unemployment Compensation Disability and Worker s Compensation Social Security and/or Supplemental SSI Benefits Public Assistance TANF SNAP etc* Other Income Number of family members in household supported by above income Optional Please advise of any extenuating circumstances that you would like us to consider. If you need additional space please write on the back of this form or use a separate sheet of paper. I HEREBY ACKNOWLEDGE THE ABOVE INFORMATION IS TRUE AND CORRECT. I AUTHORIZE QUEST DIAGNOSTICS TO VERIFY THE ABOVE INFORMATION FOR THE SOLE PURPOSE OF ASSESSING FINANCIAL NEED INCLUDING THE RIGHT TO SEEK SUPPORTING DOCUMENTATION FOR THE ABOVE REQUEST. .

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