Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
Use Form H1131 when staff transmit information containing individually identifiable health information via fax.
When to Prepare
A full-page cover sheet is required any time client 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.
Retain Form H1131 for six years.
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.