David Williams

 
 11:51 
 8005481240 
 MEW111 ADMIN DEF 
 PAGE 0/04 
 Westside Health 
 Westside Health 
 673 Chase River
West Patrick, NJ 90655 
 Phone: 361-249-7745 Fax: 270-317-3971 
 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) 
 Robert Anderson
 To: 
 270-317-3971 
 Fax 
 Attn: 
 *** Urgent 
 Phone: 
 From: 
 Amanda Anderson 
 Date: 
 2017 Mar 15
 Case Manager 
 Page(s): 
 3 
 Patient's Name: David Williams 
 DATE OF BIRTH: 1985 Jan 04 
 RE: Claim Number: 20834860154 
 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, 
 Amanda Anderson 
 Case Manager 
 Ph: 361-249-7745 
 Fax: 270-317-3971 
 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
