Medical Records Access Confidentiality Form

Employee/Personnel Information

Full Name Position/Title Department Employee ID

Access Details

Purpose of Access Type of Medical Records Accessed Date(s) of Access

Confidentiality Agreement

I acknowledge that I have been granted access to confidential medical records for legitimate purposes related to my role. I agree to maintain the confidentiality of all information obtained and will not disclose or misuse any records, in accordance with applicable laws, regulations, and organizational policies.

Signature of Employee Date

Witness Name Signature of Witness Date