Junk fax rules for healthcare practices

Practices already send referrals, records and prior authorizations by fax, so it is tempting to use the same line for outreach: a flyer announcing a new physician, a new imaging service, a lunch-and-learn or extended hours, sent to each office in the referral list. Federal law treats that kind of fax differently from a referral form or a consult note. If it advertises your services, it falls under the junk fax rules in the Telephone Consumer Protection Act, and the recipient can sue for each page run.

This guide is for practices and health businesses that market to other clinicians by fax. It covers when a fax counts as an advertisement, the permission and established business relationship rules, the opt-out notice, online fax services after the 2025 Supreme Court decision, and the damages. Protecting patient information on clinical faxes is covered in our guide to practice email and fax under HIPAA, and what you may offer a referral source is covered in our guide to patient and physician referrals.

This is general information, not legal advice. Sources cited were checked on October 30, 2026: 47 U.S.C. 227, 47 CFR 64.1200, the FCC’s 2006 Junk Fax Order (FCC 06-42), the FCC Consumer and Governmental Affairs Bureau’s 2019 Amerifactors ruling (DA 19-1247) and the Supreme Court’s June 20, 2025 decision in McLaughlin Chiropractic Associates v. McKesson Corp. State rules on fax advertising differ, so check yours, and have a health care attorney review a fax program before it starts.

The basic rule

47 U.S.C. 227(b)(1)(C) makes it unlawful to use a telephone facsimile machine, computer or other device to send an unsolicited advertisement to a telephone facsimile machine, unless three conditions are all met: the sender has an established business relationship with the recipient, the sender got the fax number in one of the permitted ways, and the fax carries an opt-out notice that meets the statute’s requirements. The FCC’s rule at 47 CFR 64.1200(a)(4) repeats those conditions and spells out the details.

Two definitions in 47 CFR 64.1200(f) decide whether the rule reaches a given fax:

Advertisement: any material advertising the commercial availability or quality of any property, goods or services.
Unsolicited advertisement: an advertisement transmitted to a person without that person’s prior express invitation or permission, in writing or otherwise.

So the questions run in order. Is the fax an advertisement? If it is, did the recipient give prior express invitation or permission? If they did not, does the established business relationship exemption apply, with an opt-out notice on the first page? If none of those holds, do not send it.

When a fax to another office is an advertisement

Your services are services, so a fax that promotes their availability or quality is an advertisement under 64.1200(f). That covers the outreach faxes practices are tempted to send to referring offices: a new provider, a new location, a new procedure, shorter wait times for referred patients, or a reminder that you take a given plan.

In its 2006 Junk Fax Order, the FCC addressed three gray areas that come up in medical outreach:

Free offers. Paragraph 52 says faxes that promote goods or services even at no cost, such as free consultations or seminars, are unsolicited advertisements, and that “free” seminars can serve as a pretext to advertise commercial products and services. A fax inviting office staff to a free lunch-and-learn about your new service line fits that description.
Informational content. Paragraph 53 says faxes that contain only information, such as industry news articles or legislative updates, are not prohibited, and that an incidental advertisement in a newsletter does not by itself convert it into an advertisement. The FCC added that a newsletter format used to advertise products or services will not protect the sender, and that it reviews these case by case.
Surveys. Paragraph 54 says surveys that serve as a pretext to an advertisement are subject to the fax advertising rules.

Faxes that carry out care are a different category. A consult note, a referral acknowledgment, a records request or a prior authorization form is sent to move a specific patient’s care forward, not to promote your services. Keep marketing content off those faxes. Adding a promotional line to a clinical fax blurs the line you need to keep clear, and it puts outreach copy next to patient information.

Use: “Dr. [Name] has joined [Practice name]. Updated referral form attached” only when the office has asked to receive your updates. Avoid: sending a “service update” to a purchased list of fax numbers because it reads like news.

Permission: the cleanest path

The rule applies to unsolicited advertisements. A fax sent with the recipient’s prior express invitation or permission is not unsolicited. The definition allows permission “in writing or otherwise”, but a spoken yes at a lunch is hard to prove later. A written record is the safer choice.

A permission record that holds up answers four questions:

Who said yes. The office name, the person’s name and role, and the fax number they gave.
To what. What kind of faxes they agreed to receive, for example new provider announcements and referral form updates from [Practice name].
When and how. The date and the channel, such as a signed sign-up card, a form on your referring provider page or an email reply.
Whether it still stands. Any later opt-out, with its date, so nobody sends to that number again.

A referring provider page on your website is a natural place to collect this. Add a short form where an office can ask to receive updates by fax or email, and store each submission with its date.

The established business relationship exemption

Without permission, an advertising fax is lawful only if all three conditions in 64.1200(a)(4) are met.

1. An established business relationship. For fax advertising, 64.1200(f)(6) defines it as a prior or existing relationship formed by a voluntary two-way communication between a person or entity and a business or residential subscriber, with or without an exchange of consideration, on the basis of an inquiry, application, purchase or transaction by the subscriber regarding products or services offered by that person or entity, which has not been terminated by either party.

Do not assume that sending or receiving referrals creates that relationship. The definition turns on an inquiry, application, purchase or transaction by the recipient about your products or services. Whether a given history of referrals meets it is a question for your attorney, and permission avoids the question.

2. A fax number from an allowed source. Under 64.1200(a)(4)(ii), the sender must have obtained the number through one of these:

The recipient gave it to the sender directly, within the established business relationship.
A directory, advertisement or website where the recipient voluntarily agreed to make the number available for public distribution. A number taken from the recipient’s own directory listing, ad or website is presumed to be made available, unless those materials say unsolicited advertisements are not accepted at that number.
A number from another source requires reasonable steps to verify that the recipient agreed to make it available for public distribution.

A purchased list of clinic fax numbers falls in the last group, and the burden of verifying it sits with the sender.

3. An opt-out notice on the first page. The next section covers what it must say.

The opt-out notice

Under 64.1200(a)(4)(iii), the notice must meet each of these requirements:

It is clear and conspicuous and on the first page. 64.1200(f)(3) adds that for faxes the notice must be at the top or bottom of the page, separate and distinguishable from the advertising copy.
It states that the recipient may ask the sender not to send future advertisements to a fax machine or machines, and that failure to comply with a valid request within 30 days is unlawful.
It sets out what a valid request must include, from 64.1200(a)(4)(iv): the fax number or numbers it covers, sent to a phone number, fax number, website or email address given in the notice.
It gives a domestic phone number and fax number for the request. If neither is toll-free, it also gives a separate cost-free way to opt out, such as a website or email address. A local number counts as cost-free if recipients are local and pay no long distance or other charges to call it.
Those numbers and the cost-free option accept opt-out requests 24 hours a day, 7 days a week.

A sample notice, to adapt with your attorney: “You may ask [Practice name] not to send future fax advertisements to your fax machine or machines. Failure to comply with your request within 30 days is unlawful. Your request must identify the fax number or numbers it covers. Send it by phone to [toll-free number], by fax to [fax number], or online at [web address], at any hour, any day.”

Test the opt-out channels before the first send, including at night and on a weekend, because the rule says they must work around the clock.

Honoring opt-out requests

64.1200(a)(4)(v) requires the sender to honor a valid request within the shortest reasonable time, not to exceed 30 days. After that, the sender may not send unsolicited advertisements to that number unless the recipient later gives prior express invitation or permission. The opt-out also ends the established business relationship exemption for future fax ads.

Two more points from the same paragraph matter when you use a vendor:

If someone other than the sender records or keeps the opt-out requests, the sender is still liable for failures to honor them.
Under 64.1200(a)(4)(vi), a fax broadcaster, defined in 64.1200(f)(7) as a person or entity that sends faxes on behalf of another for a fee, is also liable if it has a high degree of involvement in, or actual notice of, unlawful faxes and does not take steps to prevent them.

Keep one suppression list for your practice. Check it before each send, whoever does the sending.

The header on each page

Separate from the advertising rules, 47 U.S.C. 227(d)(1)(B) makes it unlawful to use a computer or other device to send a message by fax unless the sender marks, in a margin at the top or bottom of each page or on the first page of the transmission, the date and time it is sent, an identification of the business or individual sending it, and the telephone number of the sending machine or of the business. Check that your fax software fills in that header correctly, including the practice name.

Online fax services and the 2025 Supreme Court decision

Offices can receive faxes in an online inbox instead of on a paper machine. The statute covers advertisements sent to a “telephone facsimile machine”. In December 2019, the FCC’s Consumer and Governmental Affairs Bureau ruled in the Amerifactors decision (DA 19-1247) that an online fax service that effectively receives faxes sent as email over the Internet, and that cannot itself print them, is not a telephone facsimile machine. The bureau said its clarification was limited to online fax services on the record before it.

On June 20, 2025, the Supreme Court decided McLaughlin Chiropractic Associates v. McKesson Corp. The case grew out of unsolicited fax advertisements sent to medical practices. The Court held that the Hobbs Act does not bind district courts in civil enforcement proceedings to an agency’s interpretation of a statute. District courts must decide the law’s meaning themselves under ordinary principles of statutory interpretation, while giving appropriate respect to the agency’s view.

The practical point for a sender: the 2019 ruling no longer settles, in a private lawsuit, whether faxes that land in an online inbox are covered. A sender also has no reliable way to know which recipients use a paper machine and which use an online service. Plan your program as if each number reaches a fax machine covered by the rule.

What a violation can cost

47 U.S.C. 227(b)(3) lets a person or entity sue in an appropriate state court, if the state’s laws or court rules allow it, for an injunction and for actual monetary loss or 500 dollars in damages for each violation, whichever is greater. If the court finds the violation was willful or knowing, it may increase the award to up to three times that amount. The FCC can also seek forfeiture penalties under 227(b)(4), and state attorneys general can sue under 227(g).

Damages are counted per violation. A single campaign sent to a long list of offices, repeated monthly, adds up fast, and fax cases have been brought as class actions, as the 2025 Supreme Court case shows.

State law can add more. 227(f)(1) says the federal law does not preempt state laws that impose more restrictive intrastate requirements on, or prohibit, the use of fax machines to send unsolicited advertisements. State rules on fax advertising differ, so check yours.

Patient information and referral rules

An outreach fax to a referring office needs no patient information, so leave it out. Do not include patient names, case examples drawn from real patients or lists of patients the office has sent you. HIPAA safeguards for faxes that do carry patient information, such as confirming the number before sending, are covered in our guide to practice email and fax under HIPAA.

The fax rules govern how you send. Federal fraud and abuse laws govern what you offer. A fax that invites referral sources to a meal, offers a gift or ties anything of value to referrals raises Anti-Kickback Statute and Stark law questions, which our referrals guide covers. Clear both sets of rules before you send.

Outreach that asks first

Fax permission and referral relationships grow from the same habits:

A referring provider page on your website with what you treat, how to send a referral, your fax and portal details and a sign-up for updates.
Asking the office manager at each visit or call whether they want updates, and by which channel, then recording the answer.
Email updates to offices that opted in, which our healthcare email marketing guide covers.
Mailed announcements, covered in our direct mail guide.
A short, useful reply to each referral: when the patient was seen and what comes next. That is care coordination, and it does more for the relationship than a flyer.

An illustration

This example is invented. [Practice name], an orthopedic group, adds a sports medicine physician and wants to tell primary care offices nearby. A staff member has a spreadsheet of 300 fax numbers collected from a past vendor and from office websites.

Their attorney flags three problems. The vendor list has no record of how the numbers were obtained. Some office websites say they do not accept unsolicited advertisements at their fax number. And the draft flyer has no opt-out notice.

The group changes course. It sends the announcement only to the 40 offices that signed up for updates on its referring provider page or by email, adds the opt-out notice anyway as a courtesy, and mails a letter to the other offices with a link to the sign-up form. The physician’s arrival goes on the referring provider page, and the group’s fax software header now shows the practice name and number on each page.

Checklist before an outreach fax goes out

The fax is reviewed for whether it advertises services, including free events, seminars and surveys.
Each recipient has given permission, with a dated record, or the attorney has confirmed the established business relationship exemption applies.
Each fax number came from the recipient or from a source they made public, and none is marked as not accepting ads.
The opt-out notice is on the first page, at the top or bottom, with all required elements.
The opt-out phone, fax and cost-free option work 24 hours a day, 7 days a week.
The suppression list is checked before each send, and requests are honored within 30 days at the latest.
The page header shows the date, time, practice name and phone number.
No patient information appears, and the offer has been cleared for referral law.
Online fax recipients are treated the same as paper fax recipients.

How we help

We build websites, local search, Google Ads and lead generation and AI front desk tools for independent practices and health businesses. For referral outreach, that means a referring provider page with a sign-up form that records permission and the date, and referral intake that routes faxes and calls to the right person. We do not send fax campaigns. Our tools are built with HIPAA in mind. We confirm in writing what a BAA covers before any patient information flows through a tool, and if it is not covered, we do not route patient information through it. We are not a healthcare provider and we do not give legal or medical advice. For the wider rules, see our healthcare marketing rules hub.

Can a practice fax marketing to other doctors’ offices?

Only within the rules. Under 47 U.S.C. 227(b)(1)(C) and 47 CFR 64.1200(a)(4), an advertising fax needs the recipient’s prior express invitation or permission, or an established business relationship plus a fax number from an allowed source plus an opt-out notice that meets the rule on the first page.

Is a fax about a free lunch-and-learn an advertisement?

The FCC’s 2006 Junk Fax Order says faxes promoting goods or services even at no cost, such as free consultations or seminars, are unsolicited advertisements. Treat an invitation that promotes your services the same way as any other ad fax.

How fast must we honor a fax opt-out?

Within the shortest reasonable time, not to exceed 30 days, under 47 CFR 64.1200(a)(4)(v). The sender stays liable even if a vendor keeps the opt-out list.

Do the junk fax rules apply to offices that use online fax services?

A 2019 FCC bureau ruling said online fax services are not telephone facsimile machines. In June 2025 the Supreme Court held that district courts are not bound by such agency interpretations in enforcement proceedings, so the question can be reargued in court. Plan as if each number is covered.

What can a recipient recover for a junk fax?

47 U.S.C. 227(b)(3) allows actual monetary loss or 500 dollars per violation, whichever is greater, and a court may increase that up to three times for willful or knowing violations. State laws can add their own remedies.

Fax marketing to referring offices: junk fax rules for healthcare practices