Fillable FAX COVER SHEET Protected Health Information (Cameron University)

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FAX COVER SHEET Protected Health Information (Cameron University)

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Cameron University
Health Plan
FAX
COVER SHEET
Protected Health Information
Confidential Health Information Attached
Health care information is personal and sensitive. It is being faxed to you after appropriate authorization from the Member or under
circumstances that do not require Member authorization. Maintain this information in a safe, secure, and confidential manner.
Re-disclosure without additional Member consent or authorization, unless permitted by law, could subject you to penalties under
Federal and/or State law.
Date Transmitted:
Time Transmitted:
# of Pgs (including cover pg):
Intended Recipient:
Facility:
Address:
Phone #:
Fax#:
Documents:
Clinic Records
PT
Lab
X-Ray
Other:
:
Name
Date:
Time:
Please contact
at
to acknowledge receipt of this fax or to report problems with the transmission.
* * Confidentiality Statement * *
This information may include drug/alcohol drug abuse treatment records which are protected by Federal confidentiality rules (42 CFR, Part 2).
The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the
written consent of the person to whom it pertains or as otherwise permitted by 42 CFR, Part 2. A general authorization for the release of
medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate
or prosecute any alcohol or drug abuse Member. [52 FR 21809, June 9, 1987; 52 FR 41997, Nov. 2, 1987]
The information contained in this facsimile transmission is privileged and confidential and is intended for use only by the recipient listed
above. If you are neither the intended recipient nor the employee or agent of the intended recipient responsible for the receipt of this
information, you are hereby notified that the disclosure, copying, use, or distribution of this information is strictly prohibited. If you have
received this transmission in error, please notify the sender immediately by telephone to arrange for the return of the transmitted
documents or to acknowledge their destruction.
HIPAA Document
Rev 1/2015 © 2015 Attach this transmission verification to the protected health information being released.
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FAX COVER SHEET Protected Health Information (Cameron University)

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Completed 22 July 2020

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