Patient Information Confidentiality Agreement printable pdf download

Patient Information Confidentiality Agreement For All

Employee And Medical Staff

Name:

Position:

Confidentiality Agreement:

I recognize that, in the course of performing services at Montefiore Medical Center, I may gain access to Montefiore patient

information, which is required by law and by Montefiore Administrative Policy and Procedure # JH10.1 to be kept

confidential and which may be disclosed only under limited conditions that:

 I will keep confidential all patient information to which I gain access whether in the direct provision of care or otherwise.

 I will access and use patient information only on a "need to know" basis as necessary for the provision of patient services.

 I will disclose patient information only to the extent authorized and necessary to provide patient care.

 I will not discuss patient information in public places or outside of work.

I understand that it is my obligation and responsibility to ensure the confidentiality of all patient information. Improper

disclosure or misuse of patient information, whether intentional or due to neglect on my part, is a breach of Montefiore

policy, which will result in disciplinary action and could result in dismissal.

Signature:

Date:

Computer Access Agreement:

During the course of my work at Montefiore Medical Center, I may be assigned a computer identification number and

instructed to develop a personal password so that I may access Montefiore's Clinical Information System. I understand

that in order to receive an identification number and password, I will be required to complete training in the use and

responsibilities of the Montefiore Clinical Information System (CIS). I understand that my access identifiers are the

equivalent of my legal signature and I will take all reasonable and necessary precautions to protect them in order to

maintain confidentiality of patient information stored in Montefiore Medical Center's CIS system, I agree that:

I will keep my computer identification number and passwords confidential and will not share them with anyone for any

reason.

I will not leave an in-hospital or remote computer terminal unattended without first logging off.

I will take all reasonable and necessary precautions to ensure both in-hospital and remote terminals from unauthorized

access.

I will contact security administration (718-920-4554) immediately if I have reason to believe that my computer

identification number or password has been revealed.

I will report immediately to security administration (718-920-4554) any suspected unauthorized access to patient

information.

I will inform Montefiore's security administration (718-920-4554) if I leave my current employment so that my access to

Montefiore's Clinical Information System will be inactivated.

I understand that Montefiore Medical Center will use my identification number and/or password to monitor the CIS

system by means of patient and user-specific audit trails and that my use of the system may be audited at any time. I

understand that it is my obligation and responsibility to protect my computer identification number and password from

improper use, and not to do so is a breach of Montefiore policy, which will result in disciplinary action including possible

loss of access to the CIS system and/or dismissal.

Signature:

Date:

Patient Information Confidentiality Agreement