PWS_Attachment_VI_Confidentiality_Form.docx

Confidentiality Form

[Name of contract employee] has a legal and ethical responsibility to safeguard the privacy and confidentiality of all health information. In the course of my employment/assignment at (Name of MTF) ________________________, I may come into possession of confidential patient information, even though I may not be directly involved in providing patient services.

I understand that such information must be maintained in the strictest confidence. As a condition of my employment/assignment, I hereby agree that, unless directed by my supervisor, I will not at any time during or after my employment/assignment with (Name of MTF) _______________________ disclose any patient information to any person whatsoever or permit any person whatsoever to examine or make copies of any patient reports or other documents prepared by me, coming into my possession, or under my control, or use patient information, other than as necessary in the course of my employment/assignment. When patient information must be discussed with other healthcare practitioners in the course of my work/assignment, I will use discretion to ensure that, such conversations cannot be overheard by others who are not involved in the patient’s care.

I understand that violation of this agreement may result in corrective action, up to and including discharge.

Signature of Employee

Date