AGENCY FAX AGREEMENT FORM - DOC

Document Sample
AGENCY FAX AGREEMENT FORM - DOC Powered By Docstoc
					           WISCONSIN STATE LABORATORY OF HYGIENE
  INSTRUCTIONS FOR AUTO FAXING PROTECTED HEALTH INFORMATION
                         Form: #WSLH G

I request the Wisconsin State Laboratory of Hygiene to AUTO- FAX appropriate protected health
information to the number listed below.

Organization Name
Contact Person (for questions)
WSLH Agency Number(s)

Street Address
City, State, Zip
Phone Number
List preferred FAX number to be used
                                       (Note 1: Only one fax number can be used for AUTO-FAX
for:
                                       for the WSLH departments listed on the left.)
communicable diseases tests,           (Note 2: It is strongly recommended that the fax machine be
including but not limited to STDs, TB, available 24/7 to ensure receipt of reports.)
Virology; toxicology tests, including
blood lead tests; and newborn
screening tests.
 I understand that autoFAX reporting will be provided for all results for the provided agency number.
 I understand that the autoFAX report will replace the mailed report copy currently received.
 I understand my agency’s responsibilities for implementing appropriate policies and procedures, including
  physical safeguards, so that location, access, and use of our facsimile machine(s) and the information that is
  transmitted complies with State and Federal regulations for protecting the confidentiality of the patient
  protected health information.
 These instructions will remain in effect until I notify the HIPAA Privacy Coordinator at the Wisconsin State
  Laboratory of Hygiene, in writing, to discontinue or change this directive.



Authorized Signature                                              Title


Authorized Name Printed                                           Date



Please fax the completed document to the WSLH at 608-890-2548.




HIPAA form WSLH G to be used with UW HIPAA policy 8.5
D:\Docstoc\Working\pdf\67babe36-8c4f-4276-9146-323c8ef0210a.doc
Page 1 of 1
Version: May 18, 2007