UCDHS Department of Pathology and Laboratory Medicine
SECURED PRINT 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 printer IP address 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
printer 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 printer IP address 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 #
Printer location (include Building and Room #)
Phone
SECURED Printer IP address on UCD network
Printer ID
List all Doctors (first and last names) that require report transmission to this printer (add attachment if needed)
Not necessary if this is a CLIENT or STUDY account
Report transmission options (please select one)
□ Print each result immediately upon completion
□ Print report batch once daily in a.m.
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
Autoprint LIVE date
Telecom Site
Secured Printer Verification Form 08/04/11 wpd
SECURED PRINTER 09/09/10 wpd
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Provider Dictionary Updated
Initials