Free medical template
HIPAA fax cover sheet
A medical fax cover sheet with a protected health information (PHI) confidentiality notice already filled in. Add the recipient, the sender and the page count, then download it as a PDF or a Word file — free, and the details you type are never sent to FaxBolt: the file is built in your browser.
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CONFIDENTIALITY NOTICE: This facsimile may contain protected health information (PHI) covered by federal and state privacy law, including HIPAA. It is intended only for the recipient named above. If you are not the intended recipient, you are notified that any review, disclosure, copying or distribution of this information is strictly prohibited. If you received this fax in error, please telephone the sender immediately and destroy all copies, including electronic copies.
Sent with FaxBolt — send and receive faxes online at faxbolt.com
What the confidentiality notice says
The notice on this sheet tells anyone who receives the fax by mistake that it may contain protected health information, that reading, copying or forwarding it is prohibited, and that they should call the sender and destroy the pages. That wording is what most clinics, billing offices and referral coordinators expect to see on an incoming medical fax.
You can switch the notice to the plain business version, or turn it off, in the "Confidentiality notice" selector below.
What HIPAA actually requires of a fax
HIPAA does not prescribe cover-sheet wording. What the Security and Privacy Rules require is reasonable safeguards around the transmission itself, and the cover sheet is only one of them.
- Send the minimum necessary information — not the whole chart when one result is enough.
- Confirm the destination number before you send, and re-confirm numbers you use often; misdialled faxes are one of the most commonly reported breach causes.
- Do not leave PHI sitting on a shared machine — either send to a machine in a controlled area or to a service that delivers into an access-controlled inbox.
- Log what you sent and to whom, and follow your organisation's breach procedure if a fax goes to the wrong number.
- Have a signed Business Associate Agreement with any vendor that transmits or stores PHI on your behalf.
Before you fax PHI through any online service
A confidentiality notice on the cover page does not make a transmission compliant, and no cover sheet can substitute for a Business Associate Agreement. FaxBolt is a general-purpose online fax service for individuals and small businesses: it does not currently offer a BAA, so if you are a covered entity or a business associate handling PHI, use a provider that will sign one, or fax from your own equipment.
This cover sheet is free to use whichever service or machine you send from — that part does not depend on us.
Frequently asked questions
Is a HIPAA fax cover sheet required by law?
No specific cover sheet is required by HIPAA. The rules require reasonable safeguards; a confidentiality notice is the customary way to show one, and many organisations mandate it in their own policies.
What should a HIPAA fax cover sheet include?
The recipient and their fax number, the sender and a phone number for questions, the date, the total page count including the cover, and a confidentiality notice covering protected health information. Keep clinical details off the cover page itself.
Can I write the patient name on the cover sheet?
Avoid it where you can. The cover page is the one most likely to be read by whoever is standing at the machine. Use a reference number or "records enclosed" and keep identifiers on the pages behind it.
Does using this cover sheet make my fax HIPAA compliant?
No. Compliance depends on your safeguards, your policies and your agreements with vendors, not on the text of a cover page. Treat this template as one part of a process your compliance officer defines.
Does FaxBolt sign a Business Associate Agreement?
Not at the moment. If your fax carries PHI and you need a BAA, choose a provider that offers one. The cover sheet generator here stays free either way.