4. Attachment C - Non-Disclosure Agreement (NDA).pdf

Description of Agreement - Attachment C

Medical Case Reviewer For Vaccine Injury Compensation Program (VICP)

Countermeasures Injury Compensation Program (CICP) Non-Disclosure Agreement

Commitment To Protect Non-Public Information

As part of your services as a Medical Case Reviewer for the Vaccine Injury Compensation Program (VICP) and the Countermeasures Injury Compensation Program (CICP) through your interaction with the VICP/CICP Medical Officer, Department of Justice attorney, the U.S. Court of Federal Claims, and other Health Resources and Services Administration (HRSA) staff and contractors, you have access to sensitive and/or proprietary information and data.

The “sensitive and/or proprietary information and data” you have access to as part of the case file includes Personal Health Information (PHI) and Personally Identifiable Information (PII) contained in the petition, medical records, affidavits, depositions, exhibits, and other information provided to you. Sensitive and/or proprietary information and data also includes case review information, whether or not specifically related to the current case file; case review templates; Division of Injury Compensation Program (DICP), and VICP/CICP internal guidelines, policies and procedures with respect to case reviews; VICP/CICP and other related budget information, whether or not specifically related to the current case file; litigation strategy, whether or not specifically related to the current case file; Medical Analysis Branch case discussions; and other nonpublic information that you would not otherwise have access to if you did not have a contract with HRSA to provide medical case review and analysis services under the Medical Case Reviewer Blanket Purchase Agreement (BPA).

In accordance with the Non-Disclosure section in the Statement of Work found in the BPA, your dissemination or use of sensitive and/or proprietary information and data, other than in performance of your medical records review and analysis under the terms of the BPA, is considered adverse to the interests of the Federal Government and potentially others. By signing this form, you agree that you will not discuss, disclose, release, publish, or reproduce any sensitive and/or proprietary information or data, as set forth above, other than as required in the direct performance of your medical case review services under the BPA, without the prior written approval of the Contracting Officer’s Representative and the Contracting Officer responsible for administration of the Contract.1

1 If you have discussed, disclosed, released, published, or reproduced any sensitive and/or proprietary information or data, as defined above, that was not required in the direct performance of your medical case review services for the VICP/CICP prior to signing this Medical Case Reviewer Vaccine Injury Compensation Program (VICP)/Countermeasures Injury Compensation Program (CICP) Non-Disclosure Agreement, please contact the Contracting Officer’s Representative (COR) and the Contracting Officer responsible for administration of the Contract before you sign this form.

Description of Agreement -Attachment B

It is essential that the services provided under the BPA be free, to the greatest extent possible, of all conflicts of interest. By signing this form, you will not perform medical case review and analysis services for any person, or attorney representing a person, who has a claim or potential claim under the VICP/CICP.

By signing this form, you agree that you will not provide medical case review and analysis services for a claimant (a person who has made a claim under the VICP/CICP), or his/her attorney, on a claim for which you are serving or have served in the past, as a Medical Case Reviewer under the BPA. You further acknowledge that this prohibition extends beyond the period of performance of this contract.

By signing this form, you agree that you will protect sensitive and/or proprietary information and data you have access to as a result of your work on the BPA; you will comply with all requirements provided in the Case Review Guidance Memo regarding document security, including protection of PHI and PII; and that you will return, shred, or destroy all records, as directed by the VICP, within 30 days of notification of case adjudication or closure.

Violation of this agreement may subject you to civil and/or criminal penalties.

Medical Case Reviewer Signature Date

Medical Case Reviewer Typed Name

Witness Signature Date

Witness Typed Name

Copies are to be retained by:

Contracting Officer, as part of the Contract file.

Contracting Officer’s Representative, as part of the COR file and case file records.

Medical Case Review.