Fillable Printable Fax Template Cover Sheet

Fax Template Cover Sheet

HIPAA FORM 507

FAX COVER LETTER TC \l1 "ﾧ

[From: (department)]

[Name: ]

[Phone:]

[Fax:]

[Name of Health Care Provider or Practice]

[Address]

[City, state, zip code]

[Telephone number]

[Facsimile number]

Date;

Time:

Number of Pages Including Cover:

Recipient Information

To:

[Name of Authorized Receiver]

[Name of Authorized Receiver's Facility or Practice]

Telephone: Fax:

Sender Information

From:

[Name of Sender]

Telephone: Fax:

Comments:

Confidentiality Notice: Confidential Health Information Enclosed

Protected Health Information (PHI) is personal and sensitive information related to a person’s health care. It

is being faxed to you after appropriate authorization from the patient or under circumstances that do not

require patient authorization. You, the recipient, are obligated to maintain it in a safe, secure and confidential

manner. Re-disclosure without additional patient consent or as permitted by law is prohibited. Unauthorized

re-disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state

law.

IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is

addressed and may contain information that is privileged and confidential, the disclosure of which is

governed by applicable law.

If you are not the intended recipient, or the employee or agent responsible to deliver it to the intended

recipient, you are hereby notified that any disclosure, copying or distribution of this information is Strictly

Prohibited. If you have received this message by error, please notify the sender immediately to arrange for

return or destruction of these documents.