Medical Facsimile Cover Sheet printable pdf download

Medical Facsimile Cover Sheet

Medical Facsimile

Cover Sheet

Date

Name

Phone

Fax

FROM

Name

Signature

Phone

Fax

Patient Name

Identifier

Medical Record

Number

Reason For

Release

Information

Released

Total Pages

IMPORTANT: This facsimile transmission contains confidential information, some or all of

which may be protected health information as defined by the federal Health Insurance

Portability & Accountability Act (HIPAA) Privacy Rule. This transmission is intended for the

exclusive use of the individual or entity to whom it is addressed and may contain information

that is proprietary, privileged, confidential and/or exempt from disclosure under applicable

law. If you are not the intended recipient (or an employee or agent responsible for delivering

this facsimile transmission to the intended recipient), you are hereby notified that any

disclosure, dissemination, distribution or copying of this information is strictly prohibited and

may be subject to legal restriction or sanction. Please notify the sender by telephone

(number listed above) to arrange the return or destruction of the information and all copies.

Medical Facsimile Cover Sheet