CONFIDENTIALITY NOTICE: The information contained in the message and accompanying documents are legally privileged and confidential, intended only
for the use of the individual or entity named herein. If you have received this in error, please notify KHEL immediately by calling (785) 296-1620.
Rev. 3/19
LABORATORY REPORT DELIVERY
This form is used to update or add report recipient information.
Please Complete Entirely and Indicate Report Delivery Preference
Please Check One: Update Addition
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Are You the Facility that Submitted the Specimen? Yes No
Delivery Preference (Select One): Automated Fax
1
Email
2
USPS
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Are You a Primary Care Provider? Yes No
Delivery Preference: USPS (At this time, reports can only come through mail)
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Facility Name: ________________________________________________________________________________
Address: ____________________________________________________________________________________
City: ___________________________________________________ State: _______________ Zip: ____________
Secure Fax Number
1
: ____________________________ Phone Number: ________________________________
Secure Email Account
2
: ________________________________________________________________________
Report Recipient/Primary Care Provider:__________________________________________________________
1
Automated Fax reporting allows for all laboratory reports to be sent to a secure fax number.
2
Email reporting allows for all laboratory reports to be encrypted and sent to a single secure email account. It is
recommended to use an email account where multiple people have access.
By signing this request, I hereby attest that I am authorized to indicate delivery preferences for the facility above.
Printed Name (REQUIRED) Signature (REQUIRED) Date
Fax completed form to (785) 559-5205 or Email to KDHE.KHEL_Help@ks.gov
click to sign
signature
click to edit
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