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SUBJECT: Fax Confidentiality and Security Policy
SCOPE: All Employees
PURPOSE: To Establish a Process for Sending and Receiving Faxes Containing Confidential Information
Policy Statement
VSU Associates may not use or disclose confidential
information except in accordance with applicable VSU policies and
procedures. In furtherance of these policies
and procedures, it is the policy of
Associates: includes, but is not limited to, all residents, physicians, volunteers, affiliated students, vendors, contractors and any external agencies that have access to confidential information about VSU or its patients.
Questions about faxing information should be directed to the Privacy Officer.
A. Fax Restrictions
The following types of medical information are given special protection by federal and/or state law, and it therefore is VSU' policy that such information may NOT be faxed or photocopied for use outside VSU without specific written patient authorization or approval of the VSU Privacy Officer:
* Confidential details of :
* Psychotherapy (from records of treatment by a psychiatrist, licensed psychologist or psychiatric clinical nurse specialist)
* Other professional services of a licensed psychologist
* Social Work Counseling/Therapy
* Domestic Violence Victims' Counseling
* Sexual Assault Counseling
* HIV test results (written patient authorization required for EACH release request)
* Records pertaining to sexually transmitted diseases
* Alcohol and drug abuse records that are protected by law.
B. Fax Requirements
Department Directors are responsible for locating fax machines in secure areas that have limited access.
a. The first page of each fax transmission should be the VSU fax cover page (form #) and should include the following information: sender's name, sender's voice number, sender's fax number, recipient's name, recipient's voice number, recipient's fax number, transmission date and time, and number of pages including the cover sheet and the VSU standard confidentiality statement.
b. The sender must limit the information transmitted to the minimum necessary to meet the requestor's needs.
c. For confidential documents, all pages, including the cover page, must be marked "confidential" before they are transmitted.
d. The sender must make reasonable efforts to ensure send the fax is sent to the correct destination. The sender must verify the fax number before sending the fax and verify the recipient's authority to receive confidential information. Frequently used numbers should be programmed into the fax machine to prevent misdialing errors. After a number has been programmed, a test fax must be sent to the new number and receipt of that fax must be verified before confidential information is transmitted using the programmed number.
e. A sender must report any misdirected fax to the Privacy Officer immediately.
2. Receiving Faxes
a. Each department is responsible for ensuring that incoming faxes are properly handled. A fax should not be left sitting on or near the machine, but rather should be distributed to the proper recipient expeditiously while protecting confidentiality during distribution, such as by sealing the fax in an envelope.
b. Destroy confidential information faxed to VSU in error, and immediately notify the sender.
C. Enforcement
Any violation of this policy may result in disciplinary action including termination, and may be subject to penalties under state and federal law.
Policy Review Responsibility Vice President, Information Services