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Maine Fax Transmittal Form
Category:
State:
Multi-State
Control #:
US-141-AZ
Format:
Word;
PDF;
Rich Text
Instant download
Description
How to fill out Fax Transmittal Form?
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FAQ
The information is intended only for the use of the individual(s) or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or taking of any action in reliance on the contents of this facsimile information is strictly prohibited.
It typically includes information such as the sender and recipient's name and contact information, patient's name and medical record number, a brief description of the information being transmitted, and a statement confirming that the information is confidential and protected by HIPAA.
What Information to Include on a HIPPA Fax Cover Sheet Receiver Information. This category includes the name and fax number of the receiver of the fax. ... Sender Information. ... Patient Name and Reference Number. ... Date and Time Sent. ... Number of Pages on Cover Sheet. ... HIPAA Disclaimer. ... Sample HIPAA Disclaimer. ... Sources.
What information should be included on the cover sheet for fax transmissions from a medical office? Name of the office, name of the sender, name of the recipient, telephone numbers of both sender and recipient, fax number of the recipient, a confidentiality statement.
A fax cover sheet typically includes the recipient's name and fax number, the sender's name and fax number, the number of pages being sent, and a brief message or subject line. It may also include the date, the fax machine's phone number, and any additional information or instructions.
Your HIPAA cover sheet should include the following: The date and time the fax was transmitted. The receiver's name and fax number. The sender's name and fax number.
HIPAA cover sheet disclaimer A HIPAA cover-page must have a disclaimer that identifies that the content of the fax is ePHI and provide instructions on what to do if received unintentionally.
An example of a fax disclaimer statement: If you are not the intended recipient, please be advised that any disclosure, copying, distribution, or use of the contents of this information is strictly prohibited, and that any misdirected or improperly received information must be returned to this company immediately.
