Free Medical Records Fax Cover Sheet Template
Medical Records Fax Cover Sheet
FAX |
Date: August 19, 2050
To: Sarah Johnson
Insurance Company: HealthGuard Insurance
Fax Number: 222 000 3333
Phone Number: 222 000 1111
From: [YOUR NAME]
Healthcare Provider: [YOUR COMPANY NAME]
Fax Number: 222 000 5555
Phone Number: [YOUR COMPANY NUMBER]
Subject: Insurance Claims - Medical Records
Number of Pages (including cover sheet): 6
Message
Patient Name: Michael Thompson
Patient Date of Birth: February 15, 2030
Patient ID Number: 123456789
Claim Number: HG2050-7890
Comments/Additional Information:
Please find enclosed the medical records for Michael Thompson related to the recent insurance claim. These documents include treatment details and billing information pertinent to claim number HG2050-7890. If you need any further information or additional documentation, please do not hesitate to contact us.
Confidentiality Notice:
This fax transmission contains confidential information intended solely for the recipient. If you have received this document in error, please notify the sender immediately by telephone and return the original fax to the sender. Unauthorized use, disclosure, or distribution of this information is prohibited.
Attachments:
-
Treatment Summary
-
Billing Statement
-
Diagnostic Report
Signature:
[YOUR NAME]
[YOUR COMPANY NAME]
[YOUR COMPANY NUMBER]
