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Jun. 23 2000 11:24FaM Pl <br />III IIIIIIIIIIIII III <br />The Memorial Hospital <br />CONFIDENTIAL PATIE>'IT INFORMATION <br />FACSIMILE/TELECOPIEiR COVER SHEET <br />FOR IMMEDIATE DELIVERY <br />PLEASE TRANSMIT THE FOLLOWING DOCUMENT(:i) TO: <br />RECIPIENT'S FAX NUMBER: ~~ r <br />ATTENTION: <br />COMPANY NAME: ~ <br />SUBJECT: __~ <br />NUMBER OF PAGES: <br />DATE: <br />785 Russell Street <br />Craig, Colorado 81625 <br />(970) 6249411 <br />IMPORTANT NOTICE. TO RECEIVER <br />ff you do not receive all pages, please call as soon a:s possible. Our telephone number 970} 824 <br />9411, extension 3100. The Hospital facsimile number is (970) 8242235. <br />CONFIDENTIALITY NOTICE <br />This facsimile transmission (and/or the documents accompanying it) may. contain confidential <br />information belonging to the sender which is protE:cted by the physician/patient privilege. The <br />information is intended only for the use of the individual(s) or entity named above. If you are not the <br />intended recipient, you are hereby notified that any disclosure, copying, distribution, or the taking of <br />any action in reliance on the contents of this information is prohibited by law. If you have received this <br />Vansmission in error, please immediately notify us by telephone to arrange for return of the documents. <br />AUTHORIZATION FOR THIS FACSIMILE <br />The patient had provided authorization for this facsimile and the person attesting to this authorization <br />is: <br />r~~S~.c1 <br />Nam of person stating that patient <br />has authorized facsimile <br />_ ~~~ <br />Name of Hospital personnel who received <br />vernal attestation that patient authorized <br />facsimile. <br />10/92 <br />