This form is intended to ensure the confidentiality and security of protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA). Please read and sign below.

Confidentiality Commitment

I understand that all patient information, whether spoken, written or electronic, is confidential.
I agree not to disclose any patient information to unauthorized persons or entities.
I acknowledge that unauthorized disclosure or misuse of patient information may result in disciplinary and/or legal action.
I will take all reasonable steps to safeguard patient data and comply with all relevant HIPAA rules and applicable policies.

Employee/Associate Information

Name:

Title/Position:

Department:

Date:

Signature

Signature:

Office Use Only

Reviewed by:

Date:

HIPAA Confidentiality Agreement

Confidentiality Commitment

Employee/Associate Information

Signature

Office Use Only