(If the statement is from only one parent/guardian, you must also show proof that that parent/guardian has sole custody.) The statement must include a photocopy of both parents/guardians’ identifications (front and back). Please note: We may ask for additional information (e.g., custody order, incarceration order, restraining order) to protect against international parental child abduction.Ī third party (someone other than the parent/guardian) applied in person for the child’s passport (for example, a grandparent)Ī notarized statement from both parents/guardians giving the third party permission to apply for the child. Please complete the form with as much detail as possible. Submit a photocopy of the front and back of the ID that they presented to the notary publicįorm DS-5525 “Statement of Exigent/Special Family Circumstances" filled out by you.Sign and date Form DS-3053 in the presence of a certified notary public.One parent was unable to go in person to apply for the child’s passport (but both of you have custody)įorm DS-3053 “Statement of Consent” filled out by the parent who did not appear in person to apply for the child’s passport. A certified copy of the death certificate of the other parent.A complete copy of a judicial declaration of incompetence of the parent that cannot appear in person (photocopy of the complete declaration is acceptable).A certified copy of an adoption decree listing you as the only parent.A certified copy of the child’s birth certificate listing you as the only parent.A complete court order specifically permitting you to apply for your child’s passport (photocopy is acceptable).A complete court order granting you sole legal custody of the child, such as a.You have sole legal custody, or you are the only parent For your organization’s own liability risks, this statement should never be left off your cover sheet.If only one (or neither) parent or guardian applied in person for the child’s passport, we may have a question about parental consent. Including an industry compliance fax disclaimer on your cover sheet is also important should the fax be mistakenly delivered to someone other than the intended recipient.įor example, a HIPAA fax disclaimer on the cover sheet directly notifies the recipient that reviewing, disclosing, and distributing the information in the document are prohibited. If a fax is erroneously delivered to the wrong organization, the cover sheet clearly displays who sent the document and how to reach them. Correct recipientĬover sheets provide contact info for the sender. If a recipient’s documents are received by a traditional fax machine, a cover sheet keeps the information protected from view when that fax lands in the document tray.Įven if the recipient gets faxes via email, the cover sheet will protect the contents from being seen by the wrong user-in situations where multiple users receive emails sent to the same account. In other words, it’s an added step in protecting your organization from external factors leading to a violation. Privacyįax cover sheets mitigate risks associated with sending sensitive data to another organization. At the same time, they also include details such as the sender, recipient, subject, and other information such as time and date. What are fax cover sheets?įax cover sheets are the first page of your fax message that protects the confidential information within. This happens to thousands of healthcare businesses every day. On the practice manager’s end, it’s their fault for not protecting the patient’s sensitive information. What ends up happening, though, is that the records print out at the specialist’s office and sit on the printer’s shelf for the entire day.Īnyone who walks past the fax machine can easily see the patient’s records, which accounts for a HIPAA violation. The doctor needs to send a patient’s record (via Fax) to a specialist so they can prepare for the referred appointment.Ī practice manager sends the patient’s record via fax for security purposes. Imagine this: You work at a doctor’s office that sees a high volume of patients.
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