Confidential Fax Transmittal Template
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1FAX TRANSMITTAL
TO: ______________________________________________________
SUBJECT: _________________________________________________
DATE: ____________________________________________________
FAX NUMBER: _____________________________________________
PAGES (including cover): __________________________________
NOTE:
FROM:
)
CONFIDENTIALITY NOTICE: This facsimile and any documents transmitted with it are confidential and are intended solely
for the use of the individual or entity to whom they are addressed. This communication may contain material protected by the
Health Insurance Portability and Accountability Act. If you are not the intended recipient, you are hereby notified that any use of
this communication is strictly prohibited. If you have received this in error, please immediately notify our office by telephone at
412-391-7552 Also, please fax the message back to sender 412-391-6440. We appreciate your assistance in correcting this error.
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