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Fax Reporting Form

Thank you for providing information about the document you received. Your assistance will help to ensure that it reaches the correct destination. 

As stated on the fax, the document may contain legally privileged health information that may only be used by the intended recipient. Any disclosure or other use of this privileged health information is prohibited by law.

Please provide the information requested in the fields below before clicking the submit button. 

The document ID number can be found at the end of the paragraph containing the website address and phone number. Please enter the entire alphanumeric ID in the appropriate field below. 

Your information will not be shared with third parties and will only be used if we have additional questions.

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Thank you for providing information about the document you received. Your assistance will help to ensure that it reaches the correct destination. As stated on the fax, the document may contain legally privileged health information that may only be used by the intended recipient. Any disclosure or other use of this privileged health information is prohibited by law.


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