Your Company Name
Your Address
Suite #302
Any Town, USA 80111
Fax: 800-555-1212
Phone: 877-555-1212
Web: www.YourCompany.com
FAX
| To: | [Recipient Name] | ||
| [Recipient Company] | |||
| From: | [Sender Name] |
| Fax: | [Recipient Fax] | ||
| Date: | [Date] | ||
| Pages: | [Page Count] (Including Cover) |
Message: [Message]
IMPORTANT: This fax transmission contains confidential information, which may be protected health information as defined by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. This transmission is intended for the exclusive use of the individual or entity to whom it is addressed and may contain information that is proprietary, privileged, confidential, and/or exempt from disclosure under applicable law. If you are not the intended recipient (or an employee or agent responsible for delivering this facsimile transmission to the intended recipient), you are hereby notified that any disclosure, dissemination, distribution or copying of this information is strictly prohibited and may be subject to legal restriction or sanction. Please notify the sender by telephone (number listed above) to arrange the return or destruction of the information and all copies.