Confidentiality Agreement Form printable pdf download

Confidentiality Agreement Form

EMPLOYEE CONFIDENTIALITY AGREEMENT

I, the undersigned, have read and understand County policy on “Workforce Confidentiality

Policy.” In consideration of my employment or association with County and as an integral

part of the terms and conditions of my employment or association, I hereby agree that I will

not at any time, during my employment or after my employment or association ends, access

or use protected health information, or reveal or disclose to any persons within or outside

County, any protected health information except as may be required in the course of my

duties and responsibilities and in accordance with applicable local, state or federal laws

governing proper release of information.

I also understand that unauthorized use or disclosure of protected health information will

result in disciplinary action up to and including termination of employment or association and

the possible imposition of fines pursuant to applicable state and federal laws.

__________________________________

Date

__________________________________

Employee signature

__________________________________

Department

I have discussed the Workforce Confidentiality Policy and the consequences of a breach with

the above named.

___________________________________

Signature of individual administering agreement

___________________________________

Date

Page 1

Employee Confidentiality Agreement

Effective Date: April 2003

Confidentiality Agreement Form