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POLICY NO : 6065<br />
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EFFECTIVE DATE: 03/17/03<br />
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width="20">[[Human Resources]]</td>
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width="20">[[Safety/Security]] </td>
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width="20">[[Research Compliance]] </td>
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width="20">[[Compliance]]</td>
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<td style="padding:0.5em; background-color:white; line-height:0.95em; border:solid 2px #A3B1BF; border-bottom:0; font-weight:bold;" width="20">[[Privacy/Information Security]]</td>
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width="20">[[Business Operations]]</td>
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width="20">[[Intellectual Property]]</td>
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width="20">[[Faculty]]</td>
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[[Identification Card]] | [[Secure Area Card Access]] | [[Privacy/Confidentiality]] | [[Computer Use/Electronic Information]] | [[Retention and Destruction/Disposal of Private and Confidential Information]] | [[Use and Disclosure of Protected Health Information]] | [[Notice of Privacy Practices]] | [[Access to Designated Record Set]] | [[Accounting of PHI Disclosures]] | [[Patient/Consumer Complaints]] | [[Vendors]] | [[Fax Transmissions]] | [[Psychotherapy Notes]] | [[Facility Security]] | [[Conditions of Treatment Form]] | [[Informed Consent for UNMC Media]] | [[Transporting Protected Health Information]] | [[Honest Broker]] | [[Social Security Number]] | [[Third Party Registry]] | [[Information Security Awareness and Training]] | [[Patient Privacy Investigations and Levels of Violation]] | [[Use and Disclosure of PHI for Training Health Care Professionals]] | [[Disclosures of PHI as Permitted or Required by Law]] | [[Disclosure of PHI for Law Enforcement Purposes]]
<br /><br />
Policy No.: '''6065'''<br />
Effective Date: '''03/17/03'''<br />
Revised Date: '''draft 09/22/22'''<br />
Reviewed Date: ''' '''<br />


<big>'''Facsimile Transmissions Policy'''</big><br />
<big>'''Facsimile Transmissions Policy'''</big><br />
==Basis for Policy==
It is the policy of the University of Nebraska Medical Center (UNMC) to establish guidelines for use of facsimile machines to safeguard confidential information.
==Policy==
#Confidential information, including protected health information and proprietary information, may be transmitted via facsimile if reasonable safeguards are applied to protect such information from inappropriate use or disclosure.
#Accompany each transmission with a cover letter that includes:
#*Date/time of transmission
#*Sender’s and receiver’s first and last name
#*Address
#*Telephone number and fax number
#*Number of pages
#*Confidentiality statement (see example below) <blockquote>This communication, along with any attachments, is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged and confidential. If you are not the intended recipient of this communication, or the employee or agent responsible for delivering the communication to the intended recipient, you have received this communication in error and are prohibited from reading, printing, or disclosing any of the information contained in it. If you have received this communication in error, please notify the sender immediately by telephone to arrange for the return or destruction of these documents and please permanently delete and destroy this communication." </blockquote>
#Protected health information shall be transmitted in accordance with UNMC Policy 6057, [[Use and Disclosure of Protected Health Information]] and Electronic Communication of PHI procedure.
#Verify new fax numbers (including autofax) prior to using them. Never fax information to an unknown fax number. Consider pre-programming verified numbers that are frequently used into the fax machine to help avoid misdirecting any information.
#When faxing directly from the electronic medical record utilize the Communications tab.
#*Use the "Recipients" buttons to select "PCP", "Referring", etc. from the provider directory.
#*When using the “Other” recipient button, verify that the contact information added is correct.
#If a fax is received in error, notify the sender immediately, and permanently destroy the document(s).<blockquote>If a fax is sent in error, notify the recipient immediately and ask the recipient to not read the fax or its attachments and to permanently destroy the fax and its attachments, and to send an email confirming that he or she has satisfied this request.</blockquote>
#Remove faxed documents from the fax machine promptly.
#Do not install facsimile machines in high traffic areas with access to unauthorized personnel.
==Definitions==
===Individual===
The person who is the subject of the PHI. Personal representatives of the Individual have the same rights as the Individual under HIPAA (i.e., they “step into the shoes” of the Individual). Personal representatives include the legal guardian and anyone else authorized by law to act on behalf of the Individual. (See Nebraska Medicine Consents and Permits policy, MS14.)
===Protected Health Information (PHI)===
Individually identifiable health information including demographic information, collected from an Individual, whether oral or recorded in any medium, that:
*is created or received by UNMC/ACE; and
*relates to the past, present or future physical or mental health or condition of an Individual; the provision of health care to an Individual; or the past, present or future payment for the provision of health care to an Individual and identifies the Individual or with respect to which there is a reasonable basis to believe the information can be used to identify the Individual.
PHI includes genetic information, which includes information about the following items (and excludes information about an Individual’s sex or age):
*an Individual’s genetic tests;
*the genetic tests of an Individual’s family members; or
*the manifestation of a disease or disorder in such Individual’s family members (i.e., family medical history).
PHI excludes:
*individually identifiable health information of a person who has been deceased for more than fifty (50) years.
*education records covered by the Family Educational Rights and Privacy Act (FERPA); and
*employment records held by UNMC in its role as employer.
==Additional Information==
*Contact the [mailto:debrbishop@nebraskamed.com Privacy Officer]
*UNMC Policy 6057, [[Use and Disclosure of Protected Health Information]]
*UNMC Policy 6061, [[Accounting of PHI Disclosures]]
*Electronic Communication of PHI procedure
*[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/policy-for-responsible-use-of-university-computers-and-information-systems.pdf University of Nebraska Executive Memorandum 16], Policy for the Responsible Use of University Computers and Information Systems


 
This page maintained by [mailto:dpanowic@unmc.edu dkp].
NOTE: These guidelines are provided to assist UNMC workforce, including those in the patient treatment areas of the Munroe-Meyer Institute, the College of Medicine Optical Shop, the Lions Eye Bank and the College of Dentistry, as applicable, comply with HIPAA regulations. Those departments and clinics which fall under the jurisdiction of  The Nebraska Medical Center and/or University Medical Associates should consult the policies and procedures of those entities for authoritative guidance.<br />
 
 
 
=== Basis for Policy ===
<br />
 
 
It is the policy of University of Nebraska Medical Center (UNMC) to protect confidentiality and privacy through appropriate use of information gathered in the course of employment or other affiliation with UNMC or entrusted to UNMC for academic, research, patient care, or administrative purposes. <br />
 
 
 
=== Policy ===
<br />
 
 
In accordance with the Health Insurance Portability and Accountability Act of 1996  (HIPAA), Executive Memorandum No. 27, and UNMC Policy No. 6045, Privacy, Confidentiality and Information Security, and UNMC Policy No. 6057, Use and Disclosure of Protected Health Information, workforce shall use facsimile (fax) transmissions in a manner that will safeguard private and confidential information to the extent possible.
 
 
Department administration shall determine what information entrusted to their department is private and/or confidential and shall communicate methods of protecting that information from acquisition through destruction to appropriate persons associated with their department. UNMC workforce and business associates with access to private and/or confidential information will be held accountable for maintaining confidentiality.<br />
 
 
 
=== Definitions ===
<br />
 
 
'''Privacy''' is defined as the right of individuals to keep information about themselves from being disclosed.
 
'''Protected Health Information (PHI)''' is individually identifiable health information.  Health information means any information, whether oral or recorded in any medium, that:
 
   
* is created or received by UNMC; and
*    relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.
 
Records containing PHI, in any form, are the property of UNMC.  The PHI contained in the record is the property of the individual who is the subject of the record.
 
 
Protected health information excludes education records covered by the Family Educational Rights and Privacy Act (FERPA), and employment records held by UNMC in its role as employer.
 
 
Workforce refers to faculty, staff, volunteers, trainees, students, independent contractors and other persons whose conduct, in the performance of work for UNMC, is under the direct control of UNMC, whether or not they are paid by UNMC.
 
 
For more information, contact Sharon Welna, Security Officer, or see Facsimile Transmission Procedures.
 
 
Template for Fax Cover Letter / Facsimile Transmission Procedures
 
 
This is a new UNMC Policy.<br />
 
This page updated on Tuesday, August 26, 2003, by dkp.