Confidentiality Agreement - Regional One Health printable pdf download

Confidentiality Agreement

Regional One Health and its affiliates (Organization) have a legal and ethical responsibility to safeguard the privacy of all patients and

to protect the confidentiality of their health information. Additionally, the Organization must assure the confidentiality of its human

resources, payroll, financial, research, information systems, management information and any other information the Organization

classifies as confidential. I understand that, in the course of my employment/assignment at the Organization, I may come into

possession of confidential information, even though I may not be directly involved in providing patient services. Such information

may be in any form, including but not limited to: paper records, oral communications, audio recording and electronic displays. In

addition, the Personal Access Codes, including, but not limited to user id(s), password(s), and PIN(s) I use to access information

systems and/or electronically sign documents are also an integral part of this confidential information.

By signing this document I understand the following:

I agree not to disclose or discuss any patient, human resources, payroll, financial, research, information systems,

management information and any other information classified as confidential with others, including friends or family, who

do not have a need-to-know.

I agree not to access any information, or utilize equipment, other than what is required to do my job, even if I don’t tell

anyone else.

I agree not to discuss patient, human resources, payroll, financial, research, information systems, management information

and any other information classified as confidential where others can overhear the conversation, e.g. in hallways, on

elevators, in the cafeteria, on public transportation, at restaurants, or at social events.

I agree not to make inquiries for other persons who do not have proper authority.

I agree not to willing inform another person of my Personal Access Codes or knowing use another person’s Personal Access

Codes instead of my own for any reason.

I agree not to make any unauthorized transmissions, inquires, modifications, or purging of data in any system. Unauthorized

transmissions include, but are not limited to, removing and/or transferring data from the Organizations information

systems to unauthorized locations or systems, e.g. home.

I agree to log off prior to leaving any computer, laptop or terminal unattended.

I agree that I have a duty to report any breach of confidentiality that I may observe or become aware of.

I understand that violation of this agreement may result in corrective action, up to and including termination of employment and/or

suspension and loss of Organizational privileges in accordance with applicable Organizational policies. Unauthorized release of

confidential information may also result in personal, civil, and/or criminal liabilities and legal penalties.

I have read and agree to comply with the terms of the above statement, and will read and comply with Regional One Health’s

Corporate Privacy and Information Security Policies and Standards.

Name:

Emp. #

Department:

Signature:

Date:

For Organizational Use Only:

☐

Regional One Health Employee

Resident

☐

Medical Staff Physician

Volunteer

☐

Referring Physician

Student at: ________________________________

☐

Other:

Please complete and mail, scan/email, or fax back to Attn: Volunteer Services, Regional One Health, 877 Jefferson Ave., ,

Office: 901.545-7247, Fax: 901.545.8604.

Confidentiality Agreement - Regional One Health

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