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Policy No.: 6065
Effective Date: 03/17/03
Revised Date: 09/22/22
Reviewed Date: 09/22/22

Facsimile Transmissions Policy

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

1. 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.
2. 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)

     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."

3. 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.
4. 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.
5. 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.
6. If a fax is received in error, notify the sender immediately, and permanently destroy the document(s).

   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.

7. Remove faxed documents from the fax machine promptly.
8. 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 Privacy Officer
• UNMC Policy 6057, Use and Disclosure of Protected Health Information
• UNMC Policy 6061, Accounting of PHI Disclosures
• Electronic Communication of PHI procedure
• University of Nebraska Executive Memorandum 16, Policy for the Responsible Use of University Computers and Information Systems

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