Download Health Care Sample Fax Cover Sheet Template for Free

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Number of Pages:
(Including Cover Sheet)
Provider Information
Name:
Organization:
Phone:
Return
Fax:
- - -
-
Client Information
Last
Name:
First
Name:
Gender:
Date of Birth:
(MM/DD/YYYY)
CCS #:
Comments:
- -
ONE COVER SHEET PER CLIENT - UPPERCASE ONLY
fax cover sheet
To: Los Angeles County California Children's Services
Fax: (855) 481-6821
Confidentiality Notice: This fax is intended for the exclusive use of the recipient named above. It contains information that is
protected, privileged, or confidential, and it should not be disseminated, distributed, or copied to persons not authorized to
receive such information. If you are not the intended recipient, any dissemination, distribution, or copying is strictly
prohibited. If you received this fax in error, please notify the sender immediately. Thank you.
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Health Care Sample Fax Cover Sheet Template
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