Here are the samples of Fax Cover Pages submitted

These samples will be reviewed on March 13 in order to come up with a standard SeBIN Fax cover page

Ingenix

• Generic sample for filling the fields manually
• Automatically filled sample without barcode
• Automatically filled sample with horizontal barcode
• Automatically filled sample with vertical barcode

Service Lloyds

• Service_Lloyds_Fax-ATTACH_COVER.doc

Jopari

From: Sherri Wilson

To: Kepa Zubeldia

Date: Thursday May 1, 2008

Subject: The privacy language

I would recommend that we consider the following wording:

This facsimile is intended only for the use of the named addressee and may contain information that is confidential or privileged. If you are not the intended recipient, or you are not the employee responsible for delivering the facsimile for the intended recipient, you are hereby notified that any dissemination, distribution or copying of this facsimile is strictly prohibited. If you have received this facsimile in error, please notify the sender immediately.

Also I would recommend that the Fax Cover Sheet reference to Patient be changed to Employee or Injured Employee not Patient.  Also I would recommend that for Best Practices the Employee Identification be the Claim Number (if Known) and Date of Injury verses the Employee Name.