UCDHS Department of Pathology and Laboratory Medicine

SECURED FAX Transmission Verification Form

The undersigned Facility/ Client hereby authorizes UCDHS Pathology and Laboratory Medicine to send Protected Health Information (PHI) as that term is defined by the Health Insurance Portablility and Accountability Act (HIPAA, 45 C. F.R. Parts 160-164), to the following SECURED facsimile phone number to the event such transmission is determined by UCDHS Pathology and Laboratory to be a necessary component of the professional business relationship between UCDHS Pathology and Laboratory Medicine and the Client.

Client represents to the UCDHS Pathology and Laboratory Medicine that they have implemented the appropriate policy and procedures, including physical safeguards, to ensure that the location of, access to and the use of the Client’s SECURED facsimile machine complies with State and Federal laws and regulations controlling the privacy of PHI including, but not limited to HIPAA.

This Authorization will remain valid until revoked or changed by Client. To change the facsimile number or to revoke this Authorization, Client must provide written notice to: UCDHS Pathology and Laboratory Medicine at least five days prior to the implementation of the requested change or revocation. Requests maybe faxed to: UCDHS Pathology and Laboratory Medicine, Attention: Client Services at (916) 734-7371 or mailed to UCDHS Pathology and Laboratory Medicine, Attention: Client Services, 2315 Stockton Blvd., 2P616, Sacramento, California 95817.

Facility: * / Client/Study Account #
Address: * street city state zip / Phone: *
( ) -
SECURED Facsimile Number:*
( ) -
List all Doctors: (first and last names) that require report transmission to this facsimile number (add attachment if needed)Not necessary if this is a CLIENT or STUDY account *
Report transmission options (please select one) *
□Fax each result immediately upon completion
□Fax report batch once daily in a.m.
□Only fax when specified on the requisition
Additionally send hardcopy via Mail
YES NO / Report format options (please select one) *
□Final reports only
□Final reports + all preliminary reports
□Final reports + microbiology preliminaries

Facility Representative Printed Name:*______Title: *______

Facility Representative Signature: *______Date: *______

Facillity Representative email address:*______

Please sign and date this form, then fax to:

UCDHS Department of Pathology and Laboratory Medicine

Attention: Client Services @ (916) 734-7371

UCDHS USE ONLY / Autofax LIVE date / Telecom Site / □Provider Dictionary Updated / Initials

SECURED FAX TRANSMISSION 08/04/11 wpd