Aids Office Ca Agreement By Employee/contractor To Comply With Confidentiality Requirements printable pdf download

State of California—Health and Human Services Agency

California Department of Public Health

Office of AIDS

Agreement by Employee/Contractor to Comply with Confidentiality Requirements

Summary of Statutes Pertaining to Confidential Public Health Records and Penalties for Disclosure

All HIV/AIDS case reports and any information collected or maintained in the course of surveillance-related

activities that may directly or indirectly identify an individual are considered confidential public health record(s)

under California Health and Safety Code (HSC), Section 121035(c) and must be handled with the utmost

confidentiality. Furthermore, HSC §121025(a) prohibits the disclosure of HIV/AIDS-related public health records

that contain any personally identifying information to any third party, unless authorized by law for public health

purposes,

the

written

consent

the

individual

identified

the

record

his/her

guardian/conservator. Except as permitted by law, any person who negligently discloses information contained

in a confidential public health record to a third party is subject to a civil penalty of up to $5,000 plus court

costs, as provided in HSC §121025(e)(1). Any person who willfully or maliciously discloses the content of a

public health record, except as authorized by law, is subject to a civil penalty of $5,000-$25,000 plus

court costs as provided by HSC §121025(e)(2). Any willful, malicious, or negligent disclosure of information

contained in a public health record in violation of state law that results in economic, bodily, or psychological

harm to the person named in the record is a misdemeanor, punishable by imprisonment for a period of up to

one year and/or a fine of up to $25,000 plus court costs (HSC §121025(e)(3)). Any person who is guilty of a

confidentiality infringement of the foregoing type may be sued by the injured party and shall be personally

liable for all actual damages incurred for economic, bodily, or psychological harm as a result of the breach

(HSC §121025(e)(4)). Each disclosure in violation of California law is a separate, actionable offense (HSC

§121025(e)(5)).

Because an assurance of case confidentiality is the foremost concern of the California Department of Public

Health, Office of AIDS (CDPH/OA), any actual or potential breach of confidentiality shall be immediately

reported. In the event of any suspected breach, staff shall immediately notify the director or supervisor of the

local health department’s HIV/AIDS surveillance unit who in turn shall notify the CDPH/OA Surveillance

Section Chief or designee. CDPH/OA, in conjunction with the local health department and the local health

officer shall promptly investigate the suspected breach. Any evidence of an actual breach shall be reported

to the law enforcement agency that has jurisdiction.

Employee Confidentiality Pledge

I recognize that in carrying out my assigned duties, I may obtain access to private information about

persons diagnosed with HIV or AIDS that was provided under an assurance of confidentiality. I understand that

I am prohibited from disclosing or otherwise releasing any personally identifying information, either directly or

indirectly, about any individual named in any HIV/AIDS confidential public health record. Should I be

responsible for any breach of confidentiality, I understand that civil and/or criminal penalties may be brought

against me. I acknowledge that my responsibility to ensure the privacy of protected health information

contained in any electronic records, paper documents, or verbal communications to which I may gain access

shall not expire, even after my employment or affiliation with the Department has terminated.

By my signature, I acknowledge that I have read, understand, and agree to comply with the terms and

conditions above.

___________________________________

________________________________

____________

Employee name (print)

Employee Signature

Date

_____________________________

________________________________

____________

Supervisor name (print)

Supervisor Signature

Date

___________________________________

Name of Employer

P L E A S E R E T A I N A C O P Y O F T H I S D O C U M E N T F O R Y O U R R E C O R D S.

CDPH 8 6 8 9 (Revised 10/12)

Aids Office Ca Agreement By Employee/contractor To Comply With Confidentiality Requirements

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