Medical Hipaa Fax Cover Sheet - Free Download
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FACSIMILE COVER LETTER
[sending facility name]
[address]
[city, state, zip code]
[telephone number]
[facsimile number]
DATE: _______________ TIME:____________ NO. OF PAGES: ________
TO: __________________________________________________________(name of authorized receiver)
Authorized Receiver's Facility ____________________________________________________________
TELEPHONE: __________________________________FAX: _________________________________
(of receiver) (of receiver)
FROM: __________________________________________(name of sender)_______________________
TELEPHONE: __________________________________FAX: _________________________________
(of sender) (of sender)
COMMENTS:
*****CONFIDENTIALITY NOTICE*****
The documents accompanying this telecopy transmission contain confidential information belonging to the
sender that is legally privileged. This information is intended only for the use of the individual or entity named
above. The authorized recipient of this information is prohibited from disclosing this information to any other
party and is required to destroy the information after its stated need has been fulfilled, unless otherwise required
by state law. If you are not the intended recipient, you are hereby notified that any disclosure, copying,
distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have
received this telecopy in error, please notify the sender immediately to arrange for return of these documents.
