5402 25TH AVE W 2016-01-01 MF Import

JUL-11-2002 14: 1� EVERETT CLINIC E.N.T. 425 259 1155 P.01iO4 � Ev�e� Clinic Fax Cover Sheet If you believe that you have received this tax in error, please follow the enclosed inst�uctions below: The informaGon contained in this fax transmission is privileged and confidential— intended solely for the use of the individual or entity named below. If the reader is not the intended recipient, you are notified that any dissemination, copying, or distribution of this communication is strictly prohibited. If you receive this fax in error, please notify the department named below and retum/destroy the original fax to the sender. Clinic I�ocation: Gunderson Building bepartment: Ear, Nose and Throat Fax Number: 425- 9- 155 Telephone Number. 425-339.-6441 ��1 � � �j`'� Date of Fa�c: ?�� L� Company/Person Fax Sent To: I� � 2� �2-�� Fax Number of Above Company or Person: Z s � "'" U-S � Person Sending Fax: \ Z�`J A '—"� EJ �C 2��C. 6 �. Number of Pages Being Faxed to InClude Cover Sheet: � Reason for Request: In office for appointmenU Emergency Gare/L&I payment purposes/ Payment purposes/Avoidance of Repeat Tests/ Referral purposes/Other , L�� /� � Circle one. RE: CJ Comments: (Use this section to detail information sent and file fortn in Dept. Log Book) � Ir�Ei�C' C �u� � q`�V l s� 1a0w � �("1 A"C (�29 c.3b� , I � i / I ! Receipt of fax acknowledged: Yes { } No { } Prohibition of Redisclosure Of Confidential Infolmation: This confidential information has been disclosed to you from records whose confidentiality is protected by State Law (Washington 5tate Uniform Health Information Act) and Federal Law (HIPAA, Privacy and Security rules). These laws prohibit you from making further disclosure of this information without tfie specific consent oi the person to whom it pertains, or otherwise permitted by State and Federal Law. �a�oa sro2Z�