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Confidential Fax Cover Sheet 3

Confidential Fax Cover Sheet 3
Confidential Fax Coversheet
CONFIDENTIAL HEALTH INFORMATION ENCLOSED
Health Care Information is personal and sensitive information related to a person’s health care. It is being faxed to
you after appropriate authorization from the participant or under circumstances that do not require participant
authorization. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Re-
disclosure without additional participant consent or as permitted by law is prohibited. Un authorized re-disclosure or
failure to maintain confidentiality could subject you to penalties described in federal and state law.
Date: _____________________________ Number of pages: _____________________
Time: _____________________________
Sender Information Recipient Information
Name: ______________________________ Name: _______________________________
Telephone Number: __________________ Telephone Number: __________________
Fax Number: _________________________ Fax Number: _________________________
Sender, please ensure that proper authorization, Recipient – please contact the sender at the
as required by law, has been received for the number listed to verify receipt of this facsimile.
transmittal of this facsimile. Do not include
references to PHI in the message section below.
IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is
addressed, and may contain information that is confidential and legally restricted, the disclosure of which
is governed by applicable law. If the reader of this message is not the intended recipient, or the employee
or agent responsible to deliver it to the intended recipient, or the employee or agent responsible to deliver
it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this
information is STRICTLY PROHIBITED. If you have received this message by error, please notify us
immediately and destroy the related message.
4-14-03
Message:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
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