Electronic records handbook

Appendix D: Confidentiality/Non-disclosure agreement

During my employment with the __________________________, I acknowledge that I will be given access to patient information that is deemed sensitive and/or confidential.

I agree that:

1. I shall not share this information, material, or documents (information) with persons within or outside of the ____________________________ who are not authorized to have this information.
2. I shall not publish such information.
3. I shall not communicate such information without authority.
4. I shall not use or disclose any such information for other than authorized official purposes.
5. I shall not remove any such information from the premises without permission.
6. Should I receive any such information, I will accept full responsibility to ensure the confidentiality and safe-keeping of this information.
7. I shall take every reasonable step to prevent unauthorized parties from examining and/or copying and such information.

I understand that these rules apply both during and after my employment with _________________________ and that any infringement by me of these rules may be grounds for the termination of my employment and/or legal action.

___________________________________________ ______________________________________

Name

___________________________________________ ______________________________________

Signature

__________________

Date