Insert Agency Name and Address

______

XYZ Agency includes XYZ Children's Center, XYZ Work Scholarship Connection, XYZ Children’s Foundation & Corporation, & XYZ Therapeutic Foster Care Program.

FACSIMILE POLICY

  1. Regulatory Reference:

42 CFT Part 233.13 MHL

45 CFR Parts 160-164PHL 27-F; 2782

14 NYCRR 85.9; 505; 586.7; 587.7; 633..4JCAHO RI.5; IM.2; IM.7; TX.3.3

18 NYCRR 313.3; 373(a); 357.3(b)

  1. XYZ Agency Purpose Statement and Definitions:
  1. It is XYZ Agency (XYZ) policy and obligation to hold confidential all matters regarding the children and families we serve. All information in the clinical records is strictly confidential. Due to the potential breach of client confidentiality or loss of information, XYZ staff must make reasonable efforts to adhere to and protect client confidentiality and security of protected health information (PHI) when faxing PHI.
  1. For definitions, please refer to the XYZ HIPAA Glossary.
  1. XYZ Agency Policy:
  1. Applicability: This policy and procedure applies to XYZ Agency inclusive of all of its affiliates as identified above. Herein is referred to as “XYZ.”
  1. It is XYZ ’s policy that a facsimile transmission of client PHI is only used for external purposes when the original record or mail-delivered copies will not meet the needs of immediate client care and treatment. PHI shall only be transmitted via facsimile only when:

a)Urgent care is needed for the client/family;

b)Required by a third-party payer for ongoing certification of payment for a client/family currently receiving services;

c)Local, state, federal or funder expectation require it; or

d)It is a requirement of agency work processes.

  1. Disclosures in Emergencies: Allowances for permitted disclosures in emergency situations exist. Please refer to the XYZ Regulatory Policy and Procedure Cover Sheet for a list. If there are any questions, please contact the Privacy Officer or a Clinical Information Specialist (CIS).
  1. Fax machines must be located in an area that is secure and not open to the public. Do not use public library fax machines, or fax machines located in businesses other than Hillside. If using fax machines from home, be sure to secure the PHI as you would if faxing from work (e.g., don’t leave the information in the fax machine, utilize pre-programmed numbers).
  1. Only designated XYZ employees should have access to the fax machines.
  1. Notifications: Special notifications and considerations apply to the use, disclosure and access to PHI. Please refer to the XYZ Regulatory Policy and Procedure Cover Sheet for a list. If there are any questions, please call the Privacy Officer or a CIS.
  1. Verifications: Please refer to the XYZ Regulatory Policy and Procedure Cover Sheet for methods of verification.
  1. Procedure for faxing PHI: All XYZ staff must observe the following when faxing confidential information:
  1. The information transmitted should be limited to the minimum necessary to meet the requester’s needs. Routine disclosure of PHI to insurance companies, attorneys, or other legitimate users should be made in coordination with the Clinical Information Team (CIS) and through regular mail or messenger service.
  1. Except as stated in the XYZ Disclosure of Clinical Information – Authorization NOT Required (or contact Clinical Information and/or Privacy Officer), a properly completed and signed authorization should be obtained prior to the disclosure of client PHI.
  1. All disclosures that require an authorization as stated in the XYZ Disclosure of Clinical Information – Authorization Required must adhere to the required tracking and notifications stated within the agency’s policies and procedures.
  1. Authorizations transmitted via facsimile are acceptable.
  1. When transmitting confidential client PHI, a cover page must be used. It shall include:

a)Date of fax;

b)Name, phone and fax number of person and agency to receive the fax;

c)Name, phone number and address of person and agency sending the fax;

d)A list of documents/items being faxed in general terms (e.g., psychiatric assessment, IEP, report card, immunizations, consent);

e)A statement that states: “Please call me at the above mentioned number for verification of receipt of the fax.”

f)Confidentiality statement that shall read as follows:

“In accordance with local, state, and federal law, the information transmitted is intended only for the person(s) or providers of service to which it is addressed and may contain confidential and/or privileged material. Any review, re-transmission, dissemination or other use of, or taking of any action in reliance upon, this information by person(s) other than the intended recipient is prohibited. If you have received this in error, please notify me immediately for correct destruction of this information or return this information to me. Thank you for your cooperation.”

  1. AT NO TIME IS A CLIENT’S NAME OR PHI TO BE DOCUMENTED ON THE FAX COVER PAGE BEFORE THE FAX IS SENT.
  1. After the fax has been successfully sent, the client’s name shall be written in the top right corner of the fax cover page.
  1. Reasonable measures are required to ensure the facsimile transmission is sent to the appropriate destination.

a)Destination numbers should be programmed into the fax machine;

b)Staff must call ahead to notify the recipient that the fax is being transmitted; and

c)Staff must ask the recipient to call you when they have received the fax.

d)Staff must call and inquire of the fax’s receipt if they have not heard from the person they faxed PHI to.

  1. When receiving a facsimile of client PHI:

a)Make reasonable efforts to be present when the fax is received.

b)For those areas that have a support staff located near the fax machine, they must call and notify the recipient the fax is in. AT NO TIME SHOULD PHI BE LEFT ON COUNTERS, TABLES, OR OPEN SPACES UNATTENDED.

c)Pick facsimile transmissions up right away. Do not allow them in sit in the machine for long periods of time.

d)If you are not available when the transmission is received, then you should ask someone from your team to put it in an interoffice envelope and place it in your mailbox.

e)If staff are not able to pick the fax up by the end of the day, the fax should be placed in an interoffice envelope and forwarded to them.

f)Review the information received. Be sure it is legible and that all the pages noted are present.

g)If the facsimile information is on thermal paper, make a photocopy of it for the record to avoid the fading that may occur over time. Destroy the fax paper right away.

  1. In the event that a facsimile is misdirected (either received or released) the following steps should be taken:

If a fax is received in error:

a)Notify the sender immediately and ask them what they would like you to do with the information. In most cases, they will ask you to destroy the information immediately.

If a fax is sent in error:

a)If you are notified the transmission was misdirected, verify the person you sent the fax to is not there or with the agency/company, verify the fax number, and then ask the recipient to immediately destroy the fax information.

b)Call the person who was to receive the fax and verify the number again.

XYZ Fax policy

2/27/03 ml

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