Health Information Fax Cover Sheet printable pdf download

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 recipient 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

Revised 02/18/2010

Health Information Fax Cover Sheet