UNIVERSITY POLICY

SUBJECT:	CORPORATE COMPLIANCE AND PRIVACY		TITLE:		FACSIMILE (FAX) MACHINE TRANSMITTAL OF CONFIDENTIAL, SENSITIVE OR PROTECTED HEALTH INFORMATION
CODING:	00-01-15-35:00	ADOPTED:		01/23/03		AMENDED:	01/23/03

I. PURPOSE

To ensure UMDNJ’s compliance with the Health Information Portability and Accountability Act of 1996 (HIPAA) and the Standards for Privacy of Individually Identifiable Health Information and to safeguard confidential, sensitive and Protected Health Information (PHI) transmitted by facsimile (fax).

II. ACCOUNTABILITY

Under the direction of the President, the Senior Vice President for Administration and Finance and the Senior Vice President for Academic Affairs shall ensure compliance with this policy. The Deans, Presidents/CEOs of the Healthcare Units, Vice Presidents, and the University Hospital Medical Director shall implement this policy.

III. APPLICABILITY

This policy shall apply to all confidential, sensitive or PHI protected from general access by State or Federal regulations and University policy. Confidential and sensitive information includes patient, student, employee health, personnel records, financial data and communications pertaining to such. Health information that is generated during provisions of health care to patients in any of the University’s patient care units, patient care centers or faculty practices, as well as Human Subjects research under the auspices of the University or by any of its agents in all UMDNJ schools, units, departments and University owned or operated facilities.

IV. REFERENCE

Atlantic Information Services, Inc. newsletter entitled Report on Patient Privacy-Volume1, Number 11-December 2001

V. POLICY

UMDNJ is committed to safeguarding PHI in order to fulfill its mission to patients and to operate in a manner that is consistent with applicable Federal and State laws and regulations. Consequently, UMDNJ will exercise special care regarding the location and operation of fax machines. Any incidents where incoming or outgoing faxes have compromised a patient’s right to privacy shall be immediately reported to the Director for the Office of Business Conduct, Corporate Compliance and Privacy.

A.       Requirements:

1.        Confidential FAX coversheets should be developed by departments utilizing the language in the sample Confidential Fax Cover Sheet (see EXHIBIT).

2.        Preprogrammed fax numbers must be periodically verified for accuracy.

B.       Responsibilities:

1.        Care should be exercised to limit the faxing of PHI to urgent or non-routine incidents when mail or other delivery is not feasible. In addition, the faxing of sensitive health information, such as dealing with mental health, chemical dependency, sexually transmitted diseases, HIV or other highly personal information should be avoided whenever possible.

2.        When sending a fax containing PHI, the sendor should notify the receiver whenever possible so the faxed document can be promptly retrieved upon arrival.

3.        Faxes with PHI should be placed in a secure/confidential place when they are delivered and not left in a location that is in full view of passers-by.

4.        The accuracy of the fax number should be confirmed prior to sending the fax.

VI. EXHIBIT

CONFIDENTIAL FAX COVER SHEET

By Direction of the President:

Vice President for Legal Management

EXHIBIT

SAMPLE

CONFIDENTIAL FAX COVER SHEET

“Confidential Protected Health Information Enclosed”

Protected Health Care Information is personal and sensitive information related to a person’s health care. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Re-disclosure without additional patient consent or as permitted by law is prohibited. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state law.

To:		From:
Location:		Location:
Date Sent:		Fax Number:
Time Sent:		Phone Number:
Fax Number:		Number of Pages:
Phone Number:		(Including Cover)

Urgent For Review As Requested Please Reply Please Comment

Comments:

IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this information is STRICTLY PROHIBITED. If you have received this message in error, please notify the sender immediately and arrange for the return or destruction of these documents.

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