Fax Cover Sheet

Fax

Hospital:

Fax #:

Date:

# Pages:

To:

Fax #:

Date:

# Pages:

Message:

CONFIDENTIAL HIPAA NOTICE

This fax cover sheet and the documents accompanying this fax transmission may contain confidential

information belonging to the sender which is legally privileged. The information is intended only for the use

of the individual or entity named above as recipient. If you are not the intended recipient, you are hereby

notified that any disclosure, copying, distribution or the taking of any action in reliance on or regarding the

contents of this faxed information is strictly prohibited. If you have received this fax in error, please notify us

immediately by telephone to arrange for return of the original documents to us.

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Parent category: Business