Acknowledgment of Confidentiality Form SEC IM - filable.pdf

225 KB Posted

Attached to
HVAC Evaluation for Repair and/or Replacement
Solicitation number
BPM057564
Issued by
Maryland

About this file

Written by GovTribe AI ·

This is an Acknowledgment of Confidentiality Form (IM Form #02) issued by Clifton T. Perkins Hospital Center, a Maryland state facility. The form is completed by guest speakers, lecturers, and visitors attending facility tours for informational or educational purposes. Signatories acknowledge their understanding of patient confidentiality obligations and restrictions regarding the disclosure of any patient information, including the fact of a patient's presence at the hospital. The form requires visitors to disclose any personal knowledge of or relationships with current patients of Clifton T. Perkins Hospital Center and to identify such patients by name. Visitors must also acknowledge compliance with facility security procedures, including submission to searches of person and property, and agreement not to bring alcoholic beverages, drugs, or weapons onto the premises.

The form establishes personal liability for breach of patient confidentiality, with signatories acknowledging potential exposure to damages and costs resulting from any confidentiality violations or related claims. The document requires signature and date from the visitor and must be returned to the Principal Investigator Director upon completion. The form is fillable and exists in duplicate on the document provided, indicating standard use for multiple visitors to the facility.

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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 .