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.
Client/Study Account #
Facility: *
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
Report format options (please select one) *
□ Final reports only
□ Final reports + all preliminary reports
□ Final reports + microbiology preliminaries
Additionally send hardcopy via Mail
YES
NO
Facility Representative Printed Name:*____________________________________________Title: *_________________
Facility Representative Signature: *_______________________________________________Date: *_________________
Facillity Representative email address:*___________________________________________________________________
UCDHS USE ONLY
Please sign and date this form, then fax to:
UCDHS Department of Pathology and Laboratory Medicine
Attention: Client Services @ (916) 734-7371
Autofax LIVE date
Telecom Site
□ Provider Dictionary Updated
SECURED FAX TRANSMISSION 08/04/11 wpd
Initials