That is what I meant by "e-sign". They rejected it. They could tell because there were several pages requiring signatures, and they were all exactly the same. They can also tell by the size/speed of the transfer. If only the sig is a scanned image the transfer will be much smaller than if the whole page is rasterized.
As much as hospitals charge, do you seriously believe that they aren't staffed up enough to detect fax cheaters?
Could they also tell by the crispness of the fax? I remember being amazed 20 years ago at how aligned and clear things I "printed" with my "fax modem" were. Any time you fax something physical it's every so slightly crooked and jaggy.
10 years ago I remember when the "scanner" on the Multifunction machine at the office actually faxed it, complete with header, and it would end up on the network. I gave up and scanned things with my digital camera.
At my current job, for the past 6 years, I think I've only HAD to send 3 faxes. I usually insult the recipient each time. This works best when they are your customer.