Acknowledgment of Confidentiality Form SEC IM - filable.pdf

PDF 225 KB Posted

Attached to
Mobile X-Ray Services at Clifton T. Perkins Hospital Center
Solicitation number
BPM053986
Issued by
Maryland

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Written by GovTribe AI ·

This is an Acknowledgment of Confidentiality Form issued by Clifton T. Perkins Hospital Center, a state facility in Maryland, for visitors, guest speakers, lecturers, and other non-media attendees touring the hospital. The form requires individuals to acknowledge their understanding of patient confidentiality obligations and restrictions before accessing the facility. Visitors must confirm they will not disclose any information regarding patients or evaluees, including whether an individual is admitted to the hospital. The form includes a Patient Knowledge Disclosure section requiring visitors to indicate whether they have personal knowledge of or relationships with any current patients and to provide details of any such relationships if applicable.

Visitors signing the acknowledgment form agree to submit to searches of their person and property by Hospital Security and commit to not bringing alcoholic beverages, drugs, or weapons onto the hospital premises. Signatories understand they will be held personally liable for any damages and costs arising from breaches of patient confidentiality or violations of the confidentiality agreement. The form must be completed and returned to the Project Implementation Director upon conclusion of the hospital tour.

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IM Form #02 Rev. 11/11 SEC – Visitors: Others

CLIFTON T. PERKINS HOSPITAL CENTER

ACKNOWLEDGEMENT OF OBLIGATION

OF CONFIDENTIALITY

I, of , am a guest speaker/ lecturer/ visitor attending a tour of Clifton T. Perkins Hospital Center for information/ educational purposes. I am not a member of the print or electronic media. I understand and acknowledge that any information I learn regarding [any] patient, or evaluee, including the fact that a patient or evaluee is in the hospital, is confidential and may not be released. If I should breach, or be accused of violating patient confidentiality, I will be personally liable for any damages and costs from any claim or cause of action arising from such conduct, including all costs, damages to the Hospital or State that may result from or arise in connection to the tour and release of information.

I further understand I may be subject to a search of person and property by Hospital Security, and agree not to bring any alcoholic beverages, drugs, or weapons, including a pen knife onto the Hospital premises.

PRINT NAME DATE SIGNATURE

PATIENT KNOWLEDGE DISCLOSURE

Please check the appropriate box:

No, I have no personal knowledge of and/or personal relationship with any patient of CTPHC.

Yes, I have personal knowledge of and/or a personal relationship with the following CTPHC patients:

Name: Name:

Name: Name:

Name: Name:

Please explain personal knowledge of and/or type of relationship:

PRINT NAME DATE SIGNATURE

RETURN TO PI DIRECTOR UPON COMPLETION

CLIFTON T. PERKINS HOSPITAL CENTER
ACKNOWLEDGEMENT OF OBLIGATION
OF CONFIDENTIALITY
I, of , am a guest speaker/ lecturer/ visitor attending a tour of Clifton T. Perkins Hospital Center for information/ edu...
I further understand I may be subject to a search of person and property by Hospital Security, and agree not to bring any alcoholic beverages, drugs, or weapons, including a pen knife onto the Hospital premises.
PRINT NAME DATE SIGNATURE
PATIENT KNOWLEDGE DISCLOSURE
Please check the appropriate box:
No, I have no personal knowledge of and/or personal relationship with any patient of CTPHC.
Yes, I have personal knowledge of and/or a personal relationship with the following CTPHC patients:
Name: Name: Name: Name:
Name: Name:
Please explain personal knowledge of and/or type of relationship:
PRINT NAME DATE SIGNATURE
RETURN TO PI DIRECTOR UPON COMPLETION
PRINT NAME:
DATE:
Name:
Name_2:
Name_3:
Name_4:
Name_5:
Name_6:
Please explain personal knowledge of andor type of relationship 1:
Please explain personal knowledge of andor type of relationship 2:
Please explain personal knowledge of andor type of relationship 3:
Please explain personal knowledge of andor type of relationship 4:
PRINT NAME_2:
DATE_2:
Your Name:
Company You Represent:
Check Box4: Off
Check Box3: Off

File details come from the government source that posted it. Updated .