POLICY: FAX MACHINE USE AND SECURITY
Policy Number: HIP – 4200 / Page(s): 1of 2
Approved by: / Effective Date:

PURPOSE: The purpose of this policy is to clearly identify and follow the necessary safeguards and protocol to follow when sending and receiving sensitive and confidential patient health information via Fax.

POLICY: It is the policy of this clinic to take reasonable safeguards to ensure that patient medical records and Protected Health Information (PHI) transmitted via fax are done so in such a way to comply with federal and state healthcare and privacy laws and protect against accidental or unauthorized disclosures. Whenever feasible, without creating unnecessary delay to the patient’s treatment or care, the preferred method for sending confidential or PHI is via mail. The clinic’s privacy officer or the patient’s treating doctor shall make any final determinations of question over the appropriateness of sending patient information via fax transmission.

Whenever it is deemed necessary to send patient information via fax transmission the following clinic procedures will be strictlyadhered to. Failure to do so may result in disciplinary action, up to and including termination. Accidental or unintended violations will be remedied and corrected in accordance to this clinic’s compliance and privacy policies.

PROCEDURE:

  1. Only Authorized Personnel, as permitted by this clinic’s compliance and privacy policies shall send and/or receive patient PHI transmitted or maintained in any form or medium including oral, written, and electronic. Individually identifiable health information relates to an individual health status or condition, furnishing health service to an individual, or paying or administering health care benefits to an individual. Information is considered PHI where there is a reasonable basis to believe the information can be used to identify an individualvia fax transmission.
  1. Certain highly sensitive medical records(testing or treatment for HIV or other sexually transmitted diseases; testing for cancer or other life-threatening illnesses; or the diagnosis, treatment, or referral for treatment of a mental illness and/or alcohol or substance abuse) will not be transmitted by this clinic via fax. Only in extreme cases involving a medical emergency where the Patient’s treating Doctor has deemedsuch sensitive information is necessary to assist in the treatment for the emergency medical condition will such records be sent via fax transmission.
  2. Any Fax machines located at this facility shall be located in a secure area that is not generally accessible, except to Authorized Personnel.
  1. This office will use only an approved fax cover page when sendinghealth records, PHI or other confidential/sensitive patient information.
  1. Authorized staff are to, prior to transmission:
  2. Phone the receiving recipient/facility to inform them that patient medical records and/or PHI will be faxed;
  3. Confirm the fax number;
  4. Verify that the recipient fax machine is located in a secure area. If not, request that the recipient stand by the fax machine to receive information until fully transmitted.
  5. Ensure that the fax number on the fax display matches that on the Fax cover page before transmitting the fax.
  6. Confirm the successful transmission by calling the intended recipient or by checking the fax activity confirmation report (indicates successful completion or failure of fax transmissions and the destination fax number).
  7. Place a copy of the fax cover page, or a notation in the file to indicate: the information sent, the date sent, and the recipient of such information (see Fax Cover Page) and the fax activity confirmation report in the Patient’s file.
  8. Log the outgoing fax in this clinic’s fax activity report journal.
  1. Authorized staff are, upon receipt to:
  2. Remove the full contents of the fax from the machine.
  3. Count the number of pages to ensure that all have been received. If missing or other errors, contact the sender and request that such be resent.
  4. Comply with any notification or other requests stated on the cover sheet.
  5. Document the receipt of the fax in this clinic’s fax activity report journal.
  6. Hand-deliver the contents of the fax to the intended recipient. If such will not remain in a secured area at all times, or the intended recipient is out, place the contents in a sealed envelope for delivery to the recipient at the earliest available time.
  1. If a fax is received in error, authorized personnel shall immediately:
  2. Inform the sender of the error;
  3. Note the error in this clinic’s activity report journal; and
  4. Destroy the contents of the fax.