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HTML Preview Fax Letterhead page number 1.
1
Number of Pages:
(Including Cover Sheet)
Provider Information
Name:
Organization:
Phone:
Return
Fax:
-
-
-
-
Client Information
Last
Name:
First
Name:
Gender:
Date of Birth:
(MM/DD/YYYY)
CCS #:
Comments:
-
-
ONE COVER SHEET PER CLIENT - UPPERCASE ONLY
fax cover sheet
To: Los Angeles County California Children's Services
Fax: (855) 481-6821
Confidentiality Notice:
This
fax is intended for the
exclusive use of the recipient
named above. It contains
information that is
protected,
privileged,
or
confidential,
and
it
should
not
be
disseminated,
distributed,
or
copied
to
persons
not
authorized
to
receive
such
information.
If
you
are
not
the
intended
recipient,
any
dissemination,
distribution,
or
copying
is
strictly
prohibited. If you received this fax in error, please notify the sender immediately. Thank you.
Version 3.2
Print Form
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Hire character. Train skill. | Peter Schutz