University of Arkansas for Medical Sciences Logo University of Arkansas for Medical Sciences
HIPAA Office

Fax Coversheets

UAMS Fax Cover Sheet (PDF)
UAMS Fax Cover Sheet-Word
UAMS Fax Coversheet Department Template-Word

For a FAX coversheet to be in compliance with HIPAA Policy 2.1.04 Faxing of Protected Health 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.