"Fax Cover Report Sheet" - Connecticut

Fax Cover Report Sheet is a legal document that was released by the Connecticut Department of Mental Health & Addiction Services - a government authority operating within Connecticut.

Form Details:

  • The latest edition currently provided by the Connecticut Department of Mental Health & Addiction Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut Department of Mental Health & Addiction Services.

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Download "Fax Cover Report Sheet" - Connecticut

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FAX COVER SHEET
Date:
Pages:
To:
Kevin Kunak
From:
DMHAS RD
YAS Agency:
Fax:
(860) 418-6692
Fax:
Phone: (860) 418-6731
Phone:
YAS Progress/Discharge Reports follow:
Number of reports: ________
Please check pages in each report :
Enter client
Progress Report
Discharge Page
Pregnancy Page
Parenting Page
initials:
Please fax no more than 10 reports in each submission. Thank you!
FAX COVER SHEET
Date:
Pages:
To:
Kevin Kunak
From:
DMHAS RD
YAS Agency:
Fax:
(860) 418-6692
Fax:
Phone: (860) 418-6731
Phone:
YAS Progress/Discharge Reports follow:
Number of reports: ________
Please check pages in each report :
Enter client
Progress Report
Discharge Page
Pregnancy Page
Parenting Page
initials:
Please fax no more than 10 reports in each submission. Thank you!