NATIONAL CLINICAL AND WELLNESS ACCOUNT 

           ACCEPTED AT ALL QUEST DIAGNOSTICS BLOOD COLLECTION CENTERS

QUESTIONS CALL 855-623-9355

       SPECIMENS
97564587
               MUST BE Lab Reference ID
THE OPTIONS CLEARING          TESTED
    CORPORATION
1201 S COLLEGEVILLE RD        IN A QLS
9756458720032910
9756458720032910
    COLLEGEVILLE PA 19426-2998    LABORATORY     BFW132111168194
               PARTICIPANT INFORMATION - ALL FIELDS MUST BE COMPLETED PRIOR TO COLLECTION
HARISH KUMAR MI: YADA
FIRST NAME: LAST NAME:

PARTICIPANT/UNIQUE ID: HARYADA0818 DATE OF BIRTH: 08/18/1992

X MALE     FEMALE      PREFER NOT TO ANSWER(U)

SELF IDENTIFIED GENDER:    

STREET ADDRESS/APT: 1808 SANTA FE DR APT 316 X EMPLOYEE NON-EMPLOYEE

CITY: NAPERVILLE STATE: IL ZIP: 60563 DAYTIME PHONE: 2248011369

      ACCOUNT IS CLIENT BILL ONLY  --  DO NOT COLLECT PAYMENT  --  DO NOT BILL PATIENT/THIRD PARTY
             PSC - COMPLETE INFORMATION BELOW  ----  PROCESSING - ENTER DATE AND TIME COLLECTED

DATE COLLECTED ____ / ____  / ____ TIME COLLECTED: __________  AM PM FASTING: YES NO

COLLECTORS INITIALS: ______________________________ 
               PSC SITE CODE: _____________________________
Phlebotomist Examiner Instructions    Write in Biometrics for each measurement noted below, be sure to measure in correct units.
If Biometrics Requested    If not equipped for Biometrics, have Participant Self Report.
   If not measured or self reported, write "NG" (not given) as the result.

[X] 16354 BIOMETRICS IN INCHES PROV HT:______FT ______IN WT:________LBS WAIST: ______ INCHES
INITIALS____________
BLOOD PRESSURE ______ SSTL ______ DSTL PARTIC INIT:___________
[X] CP 317381 HEART AND GLUCOSE SCREEN COLLECT 1 SST

Ordering Physician: Dr Andrew Abraham NPI 1184883993   

 

By signing this requisition form and receiving these services I acknowledge

and agree to the Terms of Service which are on the back of this requisition
97564587 97564587 97564587
or were provided to me when I registered to participate.
2003291 2003291 2003291

Participant Signature: _____________________________________________________________ YADA 97564587 97564587

Quest, Quest Diagnostics, the associated logo, and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics.
All third party marks — ® and ™ — are the property of their respective owners. ©  2000 - 2021 Quest Diagnostics Incorporated.  HARISH KUMAR 2003291 2003291
All rights reserved. QD90230-BFW. Revised 4/15.
1. Terms of Service: Quest Diagnostics represents health benefit management programs with policies in place to maintain the
confidentiality of your information consistent with Quest Diagnostics Notice of Privacy Practices, which may be found at
QuestDiagnostics.com/home/privacy/. Our Privacy of Protected Health Information (PHI) policy requires that we must obtain, maintain,
use, and disclose patient protected health information in a manner that protects patient privacy and complies with all state and federal
laws. Though this is a voluntary program, should you choose not to accept these Terms of Service, you will not be able to participate.

2. You are participating in a voluntary population health program, and by your participation you freely and voluntarily assume any risks
associated with the screening process. You must be 18 years of age or older. You consent to the collection of a blood sample from a
fingerstick or from the arm; measurement of blood pressure, height, weight, waist and/or hip measurements; the collection of a cheek
swab or blood sample for the purpose of cotinine testing to detect tobacco use, the collection of a nasal swab for the purposes of
performing a test for the detection of COVID-19 and/or to a blood draw to determine whether you have developed antibodies to COVID-
19 as applicable. You understand that collection of a blood sample involves certain potential risks which may include but are not limited
to prolonged bleeding, fainting or feeling lightheaded, bruising and multiple sticks. If the program includes the reporting of results at the
point of collection, this data should be considered preliminary, they are screening assessments only. The instrument used on-site may
yield results that vary from what would be reported if the same testing was performed by the laboratory on a specimen obtained from
your arm.

3. By participating in the population health program(s) you acknowledge, and consent to, Quest’s disclosure of the data and outcomes
of your Health Questionnaire and test results in accordance with the requirements of the Health Insurance Portability and Accountability
Act (HIPAA) and any other applicable laws. If you are providing family medical history or other genetic information through a Health
Questionnaire or test results, you are also authorizing and consenting to the use of such genetic information for the purposes of the
program as described in paragraph 4 below. If you are a spouse or dependent of another participant in the program, you are also
authorizing and consenting to the use of your genetic information in your spouse’s data. Genetic information may include, but is not
limited to, blood pressure, BMI, and blood work results such as cholesterol, glucose, and triglycerides. Your employer will not receive
your results in any form that may match the data to you; however your employer’s benefits plan, which may be self-administered, may
receive identifiable information for purposes of managing the benefits plan or administering incentives on your behalf.

4. If your employer or program sponsor selects additional health benefits management services as part of this population health
program then, at the direction of your employer or program sponsor, your data may be shared with healthcare professionals/companies
and/or your employer’s Group Health Plan representatives who offer additional services provided by your employer. Data sharing with
authorized third parties will be performed via a secure data exchange process designed to keep your personal and protected health
information secure. In no event will Quest Diagnostics sell, exchange, or otherwise disclose your data except as stated in these Terms
of Service.

5. To ensure optimal participation in a population health program, your employer or plan sponsor has engaged Quest Diagnostics to
contact you regarding your voluntary participation in the program. You may receive communications via telephone, email, and/or cell
phone text messaging that include reminders, confirmations and instructions to participate, using information that you have provided, or
that your employer and/or plan sponsor has provided to Quest Diagnostics via an eligibility file.

6. If information was provided through an eligibility file from your employer or plan sponsor, then as part of the registration process you
were asked to verify and/or update your personal information. You are responsible for the accuracy of your personal information and at
any time, you can return to the My.QuestForHealth.com site, log in, and provide additional updates to your personal information.

7. If you provided a cell phone number as a means to contact you, you acknowledge and consent that we may contact you by
telephone, voicemail and/or text message with respect to Quest Diagnostics at that number. You also consent that we may contact you
at that phone number using an automatic dialing and/or announcing device that may play pre-recorded messages. You are not required
to provide a cell phone number and participation in Quest Diagnostics population health programs is not conditioned on providing a cell
phone number. If you wish to be contacted at another number or by another means, please edit your profile information at
My.QuestForHealth.com. By accepting these terms, you consent to receiving these contacts intended to provide helpful and timely
guidance regarding these services.

8. Use of the information collected through participation in this program is limited to the purposes stated in this notice. The personal
information collected or generated through participation in this program is retained for as long as is required by applicable state and
federal laws. Upon the expiration of that retention period it is disposed of in a secure manner compliant with the requirements of HIPAA.

9. The information you receive from participating in this program does not constitute the practice of medicine and is provided to you for
informational purposes only. It is not meant to replace the customary physician patient relationship. You are encouraged to share this
information with your health care provider for medical treatment purposes, or for interpretation of the results in conjunction with your
medical history, when appropriate.

10. I hereby release and discharge, to the extent permitted by law, Quest Diagnostics, my employer, my insurer/payer/third-party
administrator and of each, the controlled and controlling entities and affiliates and each of their respective officers, directors,
employees, agents and contractors, program sponsors and their related agents, from any and all claims or causes of action on account
of any injury to me which may result from my participation in this population health program. This release shall be binding upon my
heirs, assigns, executors, administrators and personal representatives.

10/16/2020