Brenda Bailey

 
 11:51 
 8005481240 
 MEW111 ADMIN DEF 
 PAGE 0/04 
 Central City Clinic 
 Central City Clinic 
 Unit 8259 Box 4602
DPO AA 22766 
 Phone: 555-510-9102 Fax: 144-237-5117 
 Facsimile Cover Sheet 
 Please call sender if not all of the pe are 
 received. 
 Please Note: The fax number you are being asked to send medical documentation to is a ax line under 
 the requirements of the Health Insurance Portability and Accountability Act. (HIPAA) 
 Eric Robinson
 To: 
 144-237-5117 
 Fax 
 Attn: 
 *** Urgent 
 Phone: 
 From: 
 Christopher Vega 
 Date: 
 18-05-01
 Case Manager 
 Page(s): 
 3 
 Patient's Name: Brenda Bailey 
 BIRTH DATE: 03-09-07 
 RE: Claim Number: 86179692132 
 STD 
 X Completed Physician Statement +attached) 
 Office Visit Notes, Return to Work Considerations-with or without Restrictions, Estimated RTV 
 Please send this information bark to our office within 48 hours as this information is requir Entercless your 
 requests to your patient. 
 Thank you, 
 Christopher Vega 
 Case Manager 
 Ph: 555-510-9102 
 Fax: 144-237-5117 
 The Genetic Information Nondiscrimination Act of 2008 
 The Genetic Information Nondiscrimination Acit of 2008 (GINA) prohibits employers and other entities covered by GI 
 
 ssistive reproductive services 
 10-10-2013 
 2013252242 
 44201503201020806 
 SEDGWICK CLAIMS MANAGEMENT SERVICES, INC. 
 [6687671-01] 190
