Form Ef03-14040 - Provider Outreach Referral Form Page 2
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1
2TEXAS HEALTH STEPS
PROVIDER OUTREACH REFERRAL SERVICES
FAX COVER SHEET
DATE:
TO: SPECIAL SERVICES UNIT
PHONE: 877-847-8377
FAX: 512-533-3867
FROM:
PHONE:
FAX:
TOTAL PAGES INCLUDING COVER SHEET:
COMMENTS:
CONFIDENTIALITY NOTICE: This fax and any pages transmitted with it are confidential and intended solely for the use of
the individual or entity to which they are intended. If you are not the intended recipient, you are hereby notified that any
use, disclosure, dissemination, distribution, copying, or taking of any action because of this information is strictly prohibited.
Please notify the sender immediately if you received this fax in error and destroy this fax and any pages transmitted with it.
EF03-14040 02/2013
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