Acknowledgment of Confidentiality Form SEC IM - filable.pdf

This is an Acknowledgment of Confidentiality Form (IM Form #02, Rev. 11/11) issued by Clifton T. Perkins Hospital Center in Maryland for visitors, guest speakers, lecturers, and other non-media attendees touring the facility for informational and educational purposes. The form serves as a binding agreement wherein signatories acknowledge their obligation to maintain strict confidentiality regarding all patient information, including the mere fact of a patient's presence at the hospital. Visitors agree to submit to security searches of their person and property and commit to not bringing alcoholic beverages, drugs, or weapons onto hospital premises. The form includes a Patient Knowledge Disclosure section requiring visitors to identify whether they have any personal knowledge of or relationships with current patients at Clifton T. Perkins Hospital Center, with space to name up to six patients and explain the nature of any relationships.

The form imposes personal liability on signatories for any breach of patient confidentiality, with violators subject to damages and costs arising from claims related to unauthorized information disclosure or other conduct connected to the tour. Visitors must provide printed names, dates, and signatures on the acknowledgment section, and the completed form must be returned to the Program/Institutional Director upon completion. The confidentiality obligations apply to all information learned during facility tours and are enforceable through potential legal action against individuals who violate patient privacy protections.