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fax transmittal form

VIEWS: 18 PAGES: 1

									                     FAX TRANSMITTAL SHEET
To: _____________________________________ Date: _________
Fax No: __________________________________ Time: _________
Telephone No: ________________________
No. of pages (including this one) __________
From: __________________________ Telephone No:____________
     Note: This transmittal is intended only for the use of the individual
or entity to which it is addressed and may contain information that is
privileged, confidential, and exempt from disclosure under applicable
law. If you are not the intended recipient, any dissemination,
distribution or photocopying of this communication is strictly
prohibited. If you have received this communication in error, please
notify this office immediately by telephone, and return the original fax
to us at the address below by US Postal Service. Thank you.

Remarks:__________________________________________________
_________________________________________________________
_________________________________________________________

    If you cannot read this fax or pages are missing, please contact:



                          PRACTON MEDICAL GROUP, INC.
                        4567 BROAD AVENUE ∙ WOODLAND HILLS, XY 12345-4700
                               OFFICE: (555) 486-9002 ∙ FAX: (555) 4887815



              INSTRUCTIONS TO THE AUTHORIZED RECEIVER:
             PLEASE COMPLETE THIS STATEMENT OF RECEIPT
           AND RETURN TO SENDER VIA THE ABOVE FAX NUMBER.

           I, _______________, verify that I have received_________________
                                                            (no. of pages including cover sheet)

              from _______________________________________________
                      (sending facility’s name)

								
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