Acknowledgment of Confidentiality Form SEC IM - filable.pdf

This is an Acknowledgment of Confidentiality Form issued by Clifton T. Perkins Hospital Center in Maryland for visitors, guest speakers, and lecturers attending facility tours for informational or educational purposes. The form establishes confidentiality obligations regarding patient information, including prohibitions on disclosing any details about patients or evaluees at the facility. Visitors must acknowledge understanding that breaches of patient confidentiality may result in personal liability for damages and costs incurred by the hospital or state. The form requires visitors to disclose any personal knowledge of or relationships with current patients at Clifton T. Perkins Hospital Center by listing patient names and explaining the nature of the relationship. Additionally, visitors must consent to security searches of their person and property, and agree not to bring alcoholic beverages, drugs, or weapons, including pocket knives, onto hospital premises.

The document contains fillable fields for visitor information, including printed name, date, and signature. Two signature sections are required—one for the confidentiality acknowledgment and one for the patient knowledge disclosure. The form must be returned to the PI Director upon completion. No pricing, funding, contract terms, or procurement-specific details are included in this document, as it functions solely as a compliance and access control mechanism for hospital visitors rather than as a procurement or contract specification document.