Acknowledgment of Confidentiality Form SEC IM - filable.pdf

This is an Acknowledgment of Confidentiality Form used by Clifton T. Perkins Hospital Center in Maryland for visitors, guest speakers, and lecturers attending tours or educational events at the facility. The form requires visitors to acknowledge their understanding of patient confidentiality obligations and certify that they are not members of the print or electronic media. Signatories must agree to maintain confidentiality regarding all patient information, including patient identities and the fact of a patient's presence at the hospital, with acknowledgment that breach of confidentiality may result in personal liability for damages and costs incurred by the hospital or state. The form also establishes terms for facility access, including consent to searches of person and property by hospital security and prohibition of alcoholic beverages, drugs, and weapons on premises.

The form includes a Patient Knowledge Disclosure section requiring visitors to disclose any personal knowledge of or relationships with current patients at Clifton T. Perkins Hospital Center. Visitors must indicate whether they have such knowledge or relationships and, if applicable, provide patient names and explain the nature of their personal knowledge or relationship. The completed form must be returned to the Principal Investigator Director upon completion. This document serves as a risk management tool to protect patient privacy in compliance with confidentiality requirements and to document visitor compliance with facility security and conduct policies.