Health Information Fax Cover Sheet
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HEALTH INFORMATION
FAX COVER SHEET
From:
To:
Fax#
Date:
Cover Sheet Plus

Pages

Comments

Confidential Health Information Enclosed. Health care information is personal and
sensitive. It is being faxed to you after appropriate authorization from the
Individual or under circumstances that do not require Individual authorization.
You, the recipient, are obligated to maintain this information in a safe, secure and
confidential manner. Re-disclosure without additional consent or authorization of
the Individual 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.

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, y