DOEA Form 190 "HIPAA Fax Cover Sheet" - Florida

What Is DOEA Form 190?

This is a legal form that was released by the Florida Department of Elder Affairs - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2003;
  • The latest edition provided by the Florida Department of Elder Affairs;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DOEA Form 190 by clicking the link below or browse more documents and templates provided by the Florida Department of Elder Affairs.

ADVERTISEMENT
ADVERTISEMENT

Download DOEA Form 190 "HIPAA Fax Cover Sheet" - Florida

Download PDF

Fill PDF online

Rate (4.7 / 5) 23 votes
Fax Cover Letter
[Name of Health Care Provider ]
[Address]
[City, state, zip code]
[Telephone number]
[Facsimile number]
Date;
Time:
Number of Pages Including Cover:
Recipient Information
To:
[Name of Authorized Receiver]
[Name of Authorized Receiver's Facility or Practice]
Telephone:
Fax:
Sender Information
From:
[Name of Sender]
Telephone:
Fax:
[Name of Health
Care Provider or
personnel]
sending fax:
Comments:
Confidentiality Notice: Confidential Health Information Enclosed
Protected Health Information (PHI) is personal and sensitive information related to a person’s health care. It
is being faxed to you after appropriate authorization from the patient or under circumstances that do not
require patient authorization. You, the recipient, are obligated to maintain it in a safe, secure and confidential
manner. Re-disclosure without additional patient consent or as permitted by law is prohibited. Unauthorized
re-disclosure or failure to maintain confidentiality could subject you to penalties described in federal and
state law.
IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is
addressed and may contain information that is privileged and confidential, the disclosure of which is
governed by applicable law.
If you are not the intended recipient, or the employee or agent responsible to deliver it to the intended
recipient, you are hereby notified that any disclosure, copying or distribution of this information is Strictly
Prohibited. If you have received this message by error, please notify the sender immediately to arrange for
return or destruction of these documents.
Florida Department of Elder Affairs
4040 ESPLANADE WAY
TALLAHASSEE, FLORIDA 32399-7000
(850)414-2000 # FAX (850)414-2007 # TDD (850)414-2001
DOEA Form 190 (04/03)
Fax Cover Letter
[Name of Health Care Provider ]
[Address]
[City, state, zip code]
[Telephone number]
[Facsimile number]
Date;
Time:
Number of Pages Including Cover:
Recipient Information
To:
[Name of Authorized Receiver]
[Name of Authorized Receiver's Facility or Practice]
Telephone:
Fax:
Sender Information
From:
[Name of Sender]
Telephone:
Fax:
[Name of Health
Care Provider or
personnel]
sending fax:
Comments:
Confidentiality Notice: Confidential Health Information Enclosed
Protected Health Information (PHI) is personal and sensitive information related to a person’s health care. It
is being faxed to you after appropriate authorization from the patient or under circumstances that do not
require patient authorization. You, the recipient, are obligated to maintain it in a safe, secure and confidential
manner. Re-disclosure without additional patient consent or as permitted by law is prohibited. Unauthorized
re-disclosure or failure to maintain confidentiality could subject you to penalties described in federal and
state law.
IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is
addressed and may contain information that is privileged and confidential, the disclosure of which is
governed by applicable law.
If you are not the intended recipient, or the employee or agent responsible to deliver it to the intended
recipient, you are hereby notified that any disclosure, copying or distribution of this information is Strictly
Prohibited. If you have received this message by error, please notify the sender immediately to arrange for
return or destruction of these documents.
Florida Department of Elder Affairs
4040 ESPLANADE WAY
TALLAHASSEE, FLORIDA 32399-7000
(850)414-2000 # FAX (850)414-2007 # TDD (850)414-2001
DOEA Form 190 (04/03)