Free HIPAA Prescription Fax Cover Sheet Template
HIPAA Prescription Fax Cover Sheet
FAX |
|---|
Date: March 7, 2050
To: Meadowview Pharmacy
Address: 456 Elm Street Anytown, USA 54321
Fax Number: (555) 789-0123
Re: Prescription Renewal Request
_____________________________________________________________________________________
Message
Dear Recipient's Name,
Please find enclosed a prescription renewal request for Mr. John Smith, a valued patient under our care. We kindly request your prompt attention to this matter.
Patient Information:
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Name: John Smith
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Date of Birth: January 15, 1965
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Prescription(s) to be Renewed:
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Medication A - 30-day supply
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Medication B - 90-day supply
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This request is made in compliance with the Health Insurance Portability and Accountability Act (HIPAA) regulations. As such, please ensure that all necessary measures are taken to maintain the confidentiality and security of the patient's medical information.
Should you require any further information or clarification, please do not hesitate to contact our office at [Your Company Number].
Thank you for your cooperation in this matter.
_____________________________________________________________________________________
Sincerely,
[YOUR NAME]
[YOUR POSITION]
[YOUR COMPANY NAME]
