fax cover sheet requesting medical records

Send a fax online with iFax

Tired of the hassle and inconvenience of traditional faxing? Say goodbye to bulky machines and paper jams.

Create a free account and choose from hundreds of professionally-made fax templates.

• Fax Cover Sheet

Medical Fax Cover Sheet

Video Tutorial How to Fill Out Medical Fax Cover Sheet

Thousands of positive reviews can’t be wrong, questions & answers.

HIPAA Coversheets

Hipaa compliant cover sheet.

• HIPAA Fax Disclaimer.
• Date and Time Fax sent.
• Receiver name and fax #.
• Sender name, organization and phone #.
• Patient’s Name and reference # if needed.

HIPAA cover sheet disclaimer

A HIPAA cover-page must have a disclaimer that identifies that the content of the fax is ePHI and provide instructions on what to do if received unintentionally. Here is a standard example:

IMPORTANT: This facsimile transmission contains confidential information, some or all of which may be protected health information as defined by the federal Health Insurance Portability & Accountability Act (HIPAA) Privacy Rule. This transmission is intended for the exclusive use of the individual or entity to whom it is addressed and may contain information that is proprietary, privileged, confidential and/or exempt from disclosure under applicable law.

If you are not the intended recipient (or an employee or agent responsible for delivering this facsimile transmission to the intended recipient), you are hereby notified that any disclosure, dissemination, distribution or copying of this information is strictly prohibited and may be subject to legal restriction or sanction. Please notify the sender by telephone (number listed above) to arrange the return or destruction of the information and all copies.

What is a HIPAA Fax Cover Sheet?

Providers may use fax machines to transmit and receive information about patients. The HIPAA regulations do not specify exactly what information a fax or fax cover sheet containing patient information should contain. However, to ensure both the privacy and security of patient protected health information (PHI), covered entities should implement measures to prevent unauthorized or accidental disclosure of PHI that is faxed. Using a HIPAA fax cover sheet is one of these measures.

What Types of PHI are in a Fax Message?

Patient medical records, billing records, lab reports, and other sensitive medical information may be transmitted via fax. These documents contain protected health information, which may consist of (among other PHI):

• Patient names;
• Patient dates of birth;
• Patient home phone number;
• Patient medical record numbers; 
• Patient health plan beneficiary numbers (health insurance ID numbers); and
• Patient Social Security numbers.

This information, as PHI, must be protected from accidental or unauthorized use or disclosure. 

To Download Your HIPAA Fax Cover Sheet Click Here

What Should a HIPAA Fax Cover Sheet Contain?

A HIPAA fax cover sheet should contain the following information:

• The name of the person who is sending the information;
• The name of the sending covered entity ;
• The phone number of the sending entity;
• The date and time the fax cover sheet is faxed;
• The fax number of the person or entity receiving the fax; and    
• A HIPAA fax cover sheet disclaimer. A HIPAA fax cover sheet disclaimer is a message addressed to the fax recipient, that states that the faxed information is confidential. The disclaimer also should state that the transmission may contain protected health information .  Finally, the HIPAA fax cover sheet disclaimer should also contain a warning that states that unauthorized viewing, reviewing, disclosing, or distributing the information in the transmission may be prohibited by the Privacy Rule or other applicable law.  

Rated #1 on G2

“compliancy group makes a highly complex process easy to understand.”, rated #1 on g2 for healthcare compliance.

What is an Example of a HIPAA Fax Cover Sheet Disclaimer?

The following is an example of a HIPAA fax cover sheet disclaimer that conveys all of this language:

“IMPORTANT: This transmission contains confidential information, which may be protected health information as defined by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. This transmission is intended for the exclusive use of the individual or entity to whom it is addressed and may contain information that is proprietary, privileged, confidential, and/or exempt from disclosure under applicable law. If you are not the intended recipient (or an employee or agent responsible for delivering this facsimile transmission to the intended recipient), you are hereby notified that any disclosure, dissemination, distribution or copying of this information is strictly prohibited and may be subject to legal restriction or sanction. Please notify the sender by telephone (number listed above) to arrange the return or destruction of the information and all copies.”

Why Should Organizations Use a HIPAA Fax Cover Sheet?

Using a fax cover sheet can keep protected health information protected from public view when the fax is received. This is so whether a healthcare provider is faxing paper documents or sending a fax via email . Having a fax transmission protected from public view can prevent those individuals who are not authorized to access a patient’s PHI or ePHI from being able to see it (whether intentional or not) when faxes are sent. 

Using a HIPAA fax cover sheet also ensures compliance with the access control standard of the Security Rule’s technical safeguard requirement. The access control standard requires entities to implement technical policies and procedures for electronic information systems that maintain ePHI, allowing access only to those persons and programs that have been given access rights. 

What Other Measures Should I Take With Respect to Faxes and Fax Cover Sheets?

To reduce the possibility of unauthorized individuals gaining access to faxed PHI or ePHI, a healthcare provider can implement the following measures:

• Store fax machines used for transmitting and receiving PHI in areas that are not accessible to the general public. 
• Verify the fax number to which the documents are being sent. Many fax machines contain an autodial function, which enables the machine to make multiple attempts to transmit a message until it is received. When using a fax machine with an autodial, healthcare employees should verify the fax number of the recipient to make sure the number is correct.
• Notify the fax recipient that you are about to send a fax transmission containing confidential patient information, so the recipient will know that a fax is on its way.
• Print out a delivery confirmation report for the message you have faxed. A delivery confirmation report indicates whether the fax transmission was successful. The report also indicates whether the recipient’s fax number was “busy,” or whether your machine is otherwise unable to transmit the message.

Modernize Your Compliance

Using automated compliance software compliance is a breeze..

Our Product

Featured Case Studies

From our blog, get in touch.

© 2023 Compliancy Group LLC. All Rights Reserved | Terms of Use | Privacy Policy

Healthcare Compliance Solved.

Medical Records Request fax cover sheet

Healthcare providers can request patient medical records with this printable HIPAA fax cover sheet.

People who printed this fax cover sheet also printed...

Copyright © 2005-2023 by Savetz Publishing , Inc. Contact us . Privacy Policy . A note from Kevin .

Subscribe to the Free Printable newsletter. (No spam, ever!)

Cover sheets in PDF format are ready to print and use. They can be opened and printed with any PDF reader.

Cover sheets in DOC format can be opened and printed with Microsoft Word and many other word processors. You can customize these files by adding your business name, address, and logo if desired.

Ready to give up your old fax machine in exchange for convenient Internet faxes? Read this FAQ on Internet fax services .

Internet Fax Price Comparison

Get easy answers to your fax questions .

More useful resources:

Send a Fax for Free from your computer

Occupational

Nature theme

Animal theme

Ready-to-use

Customizable

Foreign Language

Search Business Templates

Search Business Templates for:

Thank you for your suggestion.

We're always adding new printables, and would love to hear your suggestions. What are we missing?

Submit Suggestion    Close