Fillable Printable Health Information Fax Cover Sheet
Fillable Printable Health Information Fax Cover Sheet
Health Information Fax Cover Sheet
HEALTH INFORMATION
FAX COVER SHEET
From:
To:
Fax#
Date:
Cover Sheet Plus Pages
Comments
Confidential Health Information Enclosed. Health care information is personal and
sensitive. It is being faxed to you after appropriate authorization from the
Individual or under circumstances that do not require Individual authorization.
You, the recipient, are obligated to maintain this information in a safe, secure and
confidential manner. Re-disclosure without additional consent or authorization of
the Individual or as permitted by law is prohibited. Unauthorized re-disclosure or
failure to maintain the confidentiality of this information could subject you to
penalties under Federal and/or State law.
The information contained in this facsimile transmission is privileged and confidential and is intended
only for the use of the recipient listed above. If you are neither the intended recipient or the employee
or agent of the intended recipi ent responsible for the delivery of this information, you are hereby
notified that the disclosure, copying, use or distribution of this information is strictly prohibited. If you
have received this transmission in error, please notify us immediately by telephone at
to arrange for the return of the transmitted documents to us or to verify their destruction. Please
contact us to verify receipt of this Fax or to report probl ems with the transmission.
Revised 02/18/2010
