36C25819Q0096-010.doc

Attachment B

Southern Arizona VA Health Care System (SAVAHCS) Confidentiality Agreement

1. I, understand that, in the course of my involvement with the Veterans Health Administration (VHA) I may be given access to Protected Health Information (PHI) of the U.S. Department of Veterans Affairs and other Government contractors. For purposes of this agreement, "PHI" is health information created or received by VHA that relates to any of the following:

a. The past, present, or future physical or mental health or condition of an individual;

b. The provision of health care to an individual; or

c. The past, present, or future payment for the provision of health care to an individual

AND that does either of the following:

d. Identifies the individual, or

e. Could be used to identify the individual.

2. I agree that I will successfully complete the VHA Privacy Policy training prior to my visit to the SAVAHCS. The training is web-based and can be accessed at: https://www.tms.va.gov/learning/user/login.jsp

3. I agree that I will comply with VHA Privacy and Release of Information policy and procedures, as documented in VHA Handbook 1605.1. This Handbook may be accessed at: http://www1.va.gov/vhapublications.

4. I agree to use PHI only in the performance of work requirements necessary to carry out my duties under the above referenced contract.

5. I will report to the SAVAHCS Privacy Officer any actual or attempted violations of this agreement. I will access PHI only to the minimum extent necessary to fulfill my job duties. I will use PHI only for the purposes required and permitted by my job duties.

6. I will use reasonable and appropriate safeguards to prevent unauthorized use or disclosure of PHI in my possession.

7. I will promptly report to the facility Privacy Officer any unauthorized use of disclosure of PHI of which I become aware.

8. PHI will not be left in the "open" for viewing by unauthorized persons, nor discussed where discussions may be overheard by unauthorized persons. PHI will always be protected, especially when moved/removed from controlled areas.

9. I agree to return or certify that I have destroyed any and all PHI made available to me pursuant to my involvement with VHA and upon request by VHA, whenever the information is no longer required, upon completion of my involvement with VHA, or termination of my relationship with VHA.

10. I verify that I have read and fully understand this Agreement, and agree to abide by all requirements and restrictions contained herein. I understand that my strict compliance with the terms of this agreement is essential for the fulfillment of my obligations.

Signature

Date

Vendor Representative Name (printed) Company name, address, and telephone number