rfb-2027-dcyf-01-meald-app-c.docx

New Hampshire Department of Health and Human Services Meal & Dietary Services for the Youth Treatment Center

Appendix C

I am working at the Department of Health and Human Services, Youth Treatment Center, temporarily in order to complete work on Meal & Dietary Services for the Youth Treatment Center. My work is authorized by the Scope of Work in contract number RFB-2027-DCYF-01-MEALD during the term of the Agreement for Meal & Dietary Services.

I understand that each patient/resident at Youth Treatment Center has a right to confidentiality and to privacy about their clinical information including the fact that the patient is living at Youth Treatment Center.

I understand that any information, spoken or in writing, that identifies or potentially identifies, or is about a patient/resident may be shared among individuals who need to know the information as it is necessary for the patient/resident’s treatment or course of professional education.

I understand that patient information must be kept secure at all times, and may not be placed in or recorded by a personal electronic hardware or software, and shall be protected from any potential breach or exposure to a person or device that not authorized to see, read, or have the information.

I understand that while I am at Youth Treatment Center, these duties to protect the confidentiality of patient information apply to me.

I understand that under no circumstance may patient information be shared unless an authorization is given by the patient/resident or the patient/resident’s legal representative, or when there is a clear medical emergency.

I understand that when I am working at Youth Treatment Center, I might:

· Unintentionally see or overhear confidential health information, or personal information about a patient/resident, or

· Recognize a patient/resident when I am working.

I understand that any violation of the confidentiality is a serious offense, violates the federal Health Insurance Portability and Accountability act of 1996 (Public Law 104-191)(HIPAA), and may be grounds for legal action, breach of contract, or termination of the business relationship.

I agree that I will keep confidential and patient/resident information that I see or overhear.

I agree I will not talk about any patient/resident I might recognize, including the fact that patient resides at Youth Treatment Center.

I agree I will keep any confidential information accidentally or unintentionally learned to myself even after I complete my work at Youth Treatment Center.

I, ________________________________________ _______________________________ Signed name Printed Name have read, understand and agree to follow the statements above.

V1. Last update 1/21/22 Appendix C Confidentiality Agreement Contractor Initials:

Date:

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