Sample Confidentiality Agreement - Ucla Healthcare


Applies to all UCLA Healthcare “workforce members” including: employees, medical staff and other health
care professionals; volunteers; agency, temporary and registry personnel; and trainees, housestaff,
students, and interns (regardless of whether they are UCLA trainees or rotating through UCLA Healthcare
facilities from another institution).
It is the responsibility of all UCLA Healthcare workforce members, as defined above,
including employees, medical staff, house staff, students and volunteers, to preserve and
protect confidential patient, employee and business information.
The federal Health Insurance Portability Accountability Act (the “Privacy Rule”), the
Confidentiality of Medical Information Act (California Civil Code § 56 et seq.) and the
Lanterman-Petris-Short Act (California Welfare & Institutions Code § 5000 et seq.)
govern the release of patient identifiable information by hospitals and other health care
providers. The State Information Practices Act (California Civil Code sections 1798 et
seq.) governs the acquisition and use of data that pertains to individuals. All of these
laws establish protections to preserve the confidentiality of various medical and personal
information and specify that such information may not be disclosed except as authorized
by law or the patient or individual.
Confidential Patient Care Information includes: Any individually identifiable
information in possession or derived from a provider of health care regarding a patient's
medical history, mental, or physical condition or treatment, as well as the patients and/or
their family members records, test results, conversations, research records and financial
information. (Note: this information is defined in the Privacy Rule as “protected health
information.”) Examples include, but are not limited to:
Physical medical and psychiatric records including paper, photo, video, diagnostic
and therapeutic reports, laboratory and pathology samples;
Patient insurance and billing records;
Mainframe and department based computerized patient data and alphanumeric
radio pager messages;
Visual observation of patients receiving medical care or accessing services; and
Verbal information provided by or about a patient.
Confidential Employee and Business Information includes, but is not limited to, the
Employee home telephone number and address;
Spouse or other relative names;
Social Security number or income tax withholding records;
Information related to evaluation of performance;


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