Confidentiality Agreement Form


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.
Employee signature
I have discussed the Workforce Confidentiality Policy and the consequences of a breach with
the above named.
Signature of individual administering agreement
Page 1
Employee Confidentiality Agreement
Effective Date: April 2003


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