UAMS.EDU

HIPAA Forms

Fax Coversheets

  • UAMS Fax Coversheet-PDF
  • UAMS Fax Coversheet-Word
  • UAMS Fax Coversheet Department Template-Word


  • For a FAX coversheet to be in compliance with HIPAA Policy 2.1.04 Faxing of Protected Heatlh Information, the following notice must be included on the form:

    UAMS CONFIDENTIALITY NOTICE The information contained in this facsimile document may be privileged, confidential, and protected under applicable law and is intended solely for the use of the individual or entity to whom it is addressed. If you are not the intended recipient or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the sender immediately. If you cannot reach the sender, please contact the UAMS HIPAA Office at 501-603-1379.