Fillable Printable Fax Template Cover Sheet
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 HealthInformation(PHI)is personal andsensitiveinformation relatedtoaperson’s healthcare. It
isbeingfaxedtoyouafterappropriateauthorizationfromthepatientorundercircumstancesthatdonot
require patient authorization. You, the recipient, are obligated to maintain it in a safe, secure and confidential
manner. Re-disclosurewithoutadditionalpatientconsentoraspermittedbylawisprohibited.Unauthorized
re-disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state
law.
IMPORTANTWARNING: Thismessageisintendedfortheuseofthepersonorentitytowhichitis
addressedandmaycontaininformationthatisprivilegedandconfidential,thedisclosureofwhichis
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.
