Fivebase HIPAA Compliant Forms

Fivebase's Web Forms provide a secure (HIPAA compliant), easy to deploy and affordable means to capture patient requests.


Fivebase's Web Forms provide physician, medical and behavioral health practices with a secured (HIPAA compliant), easy to deploy and affordable means to capture patient requests without having to deploy a entire portal or HIPAA compliant web server.

Sample Form

While online / web forms are the staple of most web sites, most online forms are not secure with regard to HIPAA standards. Without a secured patient portal, most practices are technically (and legally) limited to downloadable PDF forms and contact / general information forms. The latter solution is particularly troublesome as patients voluntarily, and quite knowingly, use general contact forms for all sorts of non-secured requests.

Simply encrypting a request via SSL is not enough especially if the sensitive request is transmitted to an unsecured email inbox. Using this form to email example, below is a snapshot of some of the technical requirements that need to be addressed:

  • Forced use of S/MIME certificates for all outbound email for encryption and digital signing
  • Forced use of TLS encrypted transmission for inbound and outbound email (requires a dedicated proxy server)
  • Forced use of TLS encrypted transmission for POP, IMAP, and SMTP connections from email clients (i.e. Outlook)
  • Forced authentication for POP, IMAP, and SMTP services
  • Detailed auditing of sent messages

LuxSci helps ensure HIPAA-Compliance for email and web services.

Fivebase has partnered with Luxsci.com to provide your practice with a secured form processing service, as well as the required Business Associate Agreements (BAA). Fivebase will assist you in building or converting your existing forms into custom forms, as well as, assist you with setting up and connecting forms to your Luxsci account. If you already have a web designer, you may not need us...but you will need a Luxsci.com account for secured processing. Whether we assist you or not, you can save 10% on your Luxsci order by entering in promo code: Fivebase10.

Using this service, your practice can comfortably and securely take requests from your website including:

  • Appointment Requests
  • New Intakes
  • Referral Requests
  • Medication Refills
  • Online Bill Pay (*requires merchant gateway)
  • And any form you need

Our forms work in conjunction with your existing site and can be designed to match your site. You do not have to change hosting or invest in a dedicated hardware. All you need to do is place links to the forms on your site. Your forms will reside on a secured host and are connected to secured special purpose email inboxes and / or dumped directly into a database. When a user submits a form, it transmits securely to a secured inbox in the form of raw data, printable template and an Excel attachment. You can optionally dump form data into a database. To retrieve the form and form data, simply login into the secured web mail system or configure your favorite email client to connect to the secured inbox.

We can design new forms for your practice or convert existing online forms. Base packages that support up to 3 form configurations start at $25 per month for form hosting.

Contact us today if you have questions regarding this service or would like more information:

Email: Mike Petrie
Phone: 973-615-4007