The information contained in this facsimile message is intended only for the use of the individual or entity named above. This fax may contain Protected Health Information (PHI) that is legally protected by HIPAA regulations. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you have received this fax in error, please notify the sender immediately and destroy all copies of this message.

To:
Fax Number:
From:
Phone Number:
Date:
Number of Pages (including cover):
Re:
CC:

HIPAA-Compliant Fax Cover Sheet