HIPAA Coversheets

HIPAA compliant cover sheet

A cover sheet doesn’t have to be fancy. Here are some downloadable templates. A good covers sheet has the following fields:

  • 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.