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Effective Date: 



Updated: 1/2004


Use Form 1131 when staff transmit information containing individually identifiable health information via fax.


When to Prepare

A full-page cover sheet is required any time an individual's health information (such as diagnosis) is being faxed. Complete all information on the form.

The HIPAA Notice of Confidentiality must appear on the top of the fax transmission cover sheet:

If you received this fax message in error, DO NOT PROCEED TO THE NEXT PAGE. The information on the following pages is CONFIDENTIAL and intended solely for the individual to whom this message is addressed. You are not authorized to look at this information. Please contact the sender of this message immediately for instructions.

Form Retention

Retain Form 1131 for six years.

Detailed Instructions

Sender Information — Enter the sender's region/unit, office address, mail code, city, state, and ZIP code.

Date: — Enter the date.

To: — Enter the recipient's name, state agency or company name and department, fax number, and telephone number in the appropriate spaces.

From: — Enter the sender's name, fax number, and telephone number in the appropriate spaces.

Note: The sender must confirm the accuracy of the recipient's fax number before transmitting the information. Confirm the accuracy of the number by double-checking the number written on the cover sheet and the number entered into the fax machine. The sender must telephone the recipient to confirm the fax number if the sender is not confident that the number is correct.

Re: — Enter the subject of the fax.

Pages: — Enter the number of pages, including the cover page, in the appropriate space.

Instruction Boxes — Check the appropriate instruction box(es).

Message: — Enter the message.