HIPPA Home Health Care Fax Cover Sheet

FAX

To:
Name: [Recipient's Name]
Title: [Recipient's Title]
Organization: [Recipient's Organization]
Fax Number: [Recipient's Fax Number]
Phone Number: [Recipient's Phone Number]

From:
Name: [Your Name]
Title: [Your Title]
Organization: [Your Company Name]
Fax Number: [Your Fax Number]
Phone Number: [Your Company Number]

Message

Dear [Recepient's Name],

This fax contains legally privileged health information for the specified individual or entity. Any unauthorized use is strictly prohibited. If received incorrectly, contact the sender for return or destruction.

Please find enclosed the medical records and a comprehensive care plan for our mutual patient, Jane Roe. These documents include her latest lab results, medication list, and the proposed home health care schedule designed to address her post-surgical needs. Your team's input on the care plan and any adjustments needed to better suit Ms. Roe's recovery at home would be greatly appreciated.

Additionally, we have included Ms. Roe's consent form authorizing the release and discussion of her medical information between Citywide Health Clinic and Springfield Home Health Services. Should there be any further information or clarification required, please do not hesitate to contact me directly at the number provided above.

Please confirm the receipt of this fax by contacting me at [Your Number] or via email at [Your email].

Best regards,