HIPAA Confidentiality Agreement

by | Oct 16, 2020 | curriculum

  • I acknowledge that during the course of performing my assigned duties at TWO WINGS, as an employee/intern/volunteer I may have access to, use, or disclose confidential information. I hereby agree to handle such information in a confidential manner at all times during and after my employment/internship/volunteer status and commit to the following obligations:
    1. I will use and disclose confidential information only in connection with and for the purpose of performing my assigned duties.
    2. I will request, obtain or communicate confidential information only as necessary to perform my assigned duties and shall refrain from requesting, obtaining or communicating more confidential information than is absolutely necessary to accomplish my assigned duties.
    3. I will take reasonable care to properly secure confidential information on my computer and will take steps to ensure that others cannot view or access such information. When I am away from my workstation or when my tasks are completed, I will log off my computer or use a password-protected screensaver in order to prevent access by unauthorized users.
    4. I will not disclose my personal password(s) to anyone without the express written permission of my department head or record or post it in an accessible location and will refrain from performing any tasks using another's password
    I understand that as an employee/intern/volunteer of TWO WINGS that the use and disclosure of client information is governed by the rules and regulations established under HIPAA, the Health Insurance Portability and Accountability Act of 1996, and related policies and procedures of TWO WINGS. Therefore, with regard to client information, I commit to the following additional obligations:
    1. I will use and disclose confidential information solely in accordance with the federal and TWO WINGS policies set forth above or elsewhere. I also agree to familiarize myself with any periodic updates or changes to such policies in a timely manner.
    2. I will immediately report any unauthorized use or disclosure of confidential information that I become aware of to the appropriate supervisor using the reporting procedure established at TWO WINGS.
    I also understand and agree that my failure to fulfill any of the obligations set forth in this Agreement and/or my violation of any terms of this Agreement shall result in my being subject to appropriate disciplinary action, up to and including, termination of employment/internship/volunteer status.
  • MM slash DD slash YYYY