Fax Cover Sheet - Claimaid
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1Fax Cover Sheet
Date:
TIME:
ATTN:
Fax #:
RE:
FROM:
This is page________ of_________ pages
Special Instructions:
Confidentiality Notice
This facsimile (and attachments) may contain protected health information (PHI) from ClaimAid and is
covered by the Electronic Communications Privacy Act, 18 U.S.C. 2510-2521. This information is intended
only for the use of the individual or entity named in this facsimile. Any unintended recipient is hereby
notified that the information if privileged and confidential. Any use, disclosure, or reproduction of this
information is prohibited. Any unintended recipient should contact ClaimAid by telephone at the above
number immediately and destroy this facsimile.
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