FAX COVER SHEET

 

Confidential Health Information Enclosed.  Health care information is personal and sensitive.  It is being faxed to

you after appropriate authorization from the patient or under circumstances that do not require patient authorization. 

You, the recipient, are obligated to maintain this information in a safe, secure and confidential manner.  Re-disclosure

without additional patient consent or authorization or as permitted by law is prohibited.  Unauthorized re-disclosure

or failure to maintain the confidentiality of this information could subject you to penalties under Federal and/or State law.

 

Date Transmitted:                                                        Time Transmitted:                                                                   

 

Number of Pages (including cover sheet):                                                                                          

 

Intended Recipient:                                                                                                                                                                                                   

 

Facility:                                                                                                                                                                                                                                           

 

Address:                                                                                                                                                                                                                                        

 

Telephone #:                                                                 Fax #:                                                                                          

 

Documents being Faxed:                                            Clinic Records                      PT

                                                                                        Lab                                         X-Ray

                                                                                        Other

 

Confidentiality Statement

 

The information contained in this facsimile transmission is privileged and confidential and is intended only for the use

of the recipient listed above.  If you are neither the intended recipient or the employee or agent of the intended recipient

responsible for the delivery of this information, you are hereby notified that the disclosure, copying, use or distribution

of this information is strictly prohibited.  If you have received this transmission in error, please notify us immediately

by telephone to arrange for the return of the transmitted documents to us or to verify their destruction.

 

Please contact                                                       at                                                          to verify receipt of this Fax or to

 report problems with the transmission.

 

Verification of transmission of Particularly Sensitive Health Information: 

 

I verify the receiver of this Fax has confirmed its transmission:

 

 

Name:                                                                       Date:                             Time:                       

 

 

I verify that I have confirmed the receipt of this Fax transmission by phone:

 

 

Name:                                                                       Date:                              Time: