Fax Reporting Form

Fax Reporting From

Thank you for providing information about the document you received. Your assistance will help to ensure that it reaches the correct destination.

As stated on the fax, the document may contain legally privileged health information that may only be used by the intended recipient. Any disclosure or other use of this privileged health information is prohibited by law.
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Please provide the information requested in the fields below before clicking the submit button. The Fax ID number can be found at the end of the paragraph on the cover page.

Your information will not be shared with third parties and will only be used if we have additional questions.

Your Full Name*

Your Email*

Your Phone Number*

Business Name (Optional)

Fax Received Date* (mm/dd/yyyy)

Fax ID* (included on the cover page)

By clicking submit, you understand that the disclosure or use of any privileged information contained in the document is prohibited and agree that you will not disclose or otherwise use the information contained in the document you received. You further agree to destroy the document in a manner such as shredding that renders the contents unreadable.

Thank you!

We have received your information and will follow up with you shortly. 

Need to make a quick referral? 
Please use the appropriate fax number below. No setup is required. 

Fax Instructions:

Massachusetts: 617-993-9698

North Carolina: 833-896-5765

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