Palm Beach Institute

Fax Cover Sheet

 

To:          ____________________________________         Date:         _______________

Company:          _____________________________   # Pages: ___________(including cover)

Fax #:         ____________________________________         Tel #:         _______________

From:         ____________________________________         Tel #:         ______________

______________________________________

Message:

 

 

 

 

 

 

 

 

This facsimile may contain individually identifiable patient health information. The use and disclosure of information contained in this fax is restricted by the Health Insurance Portability and Accountability Act of 1996 and is protected under The Privacy Act of 1974. It is intended for the use of the Recipient identified above. This faxed material must be destroyed appropriately when its use is no longer required. If the reader of this message is not the intended recipient or the employee or agent responsible for delivering the attached information to the intended recipient, please note that any dissemination, distribution or copying of this communication is strictly prohibited. Anyone who receives this communication in error should notify Palm Beach Institute immediately and return the original message to the address on this comer sheet via U.S. mail